Two years ago I had a really bad infection that landed me in the hospital for five days. I wasn't in a position to be asking questions about which doctors were in network, as I was on IV antibiotics and barely there mentally.
When I got home the bills started rolling in. Between the hospital, the specialist they called in, and the anesthesiologist, I was looking at just under $47,000. My insurance covered a chunk of it but left me holding about $19,000 because two of the providers were apparently out of network. With those who dont know what out of network means it means useing a provider like certain doctors who may not be convered by your insurance.
I didn't pick those providers to help me. They were just there. That's how hospitals work. They help you with whatever doctors are available because it's a life or death situation most of the time, but the insurance doesn't see it like that.
I spent weeks going back and forth with my insurer getting nowhere. A friend suggested I talk to a lawyer who specifically handles insurance claim disputes, I didn't even know that was a thing. Found one online, explained the situation, and they took it on contingency so I paid nothing upfront.
Within two months the insurer had reversed the majority of the out of network charges. My final bill was just over $800.
The thing I learned is that insurance companies are betting you don't know your rights or don't have the energy to fight. Most people just pay to be done with it. If you're dealing with something similar, at least look into it before you assume you're stuck. Don’t let them win!
If you’ve had similar experiences share to help others.
Infection to Denied Coverage
byu/PurpleReflection001 inInsurance
Posted by PurpleReflection001
2 Comments
It should have been covered by this:
The No Surprises Act (effective January 1, 2022) protects patients with private health insurance from unexpected “surprise” medical bills for emergency services, non-emergency services from out-of-network providers at in-network facilities, and out-of-network air ambulances. It limits cost-sharing to in-network levels and bans balance billing, ensuring patients pay only their deductible or copayment.
This needs more context. You say you were denied coverage, yet your insurance paid. Was the 19k a balance billing? Did you have an HMO at the time? Are you aware of the No Surprises Act that has been in effect since 1/1/22 that likely applies here? Did you contact your states DOI?
I’m glad this was resolved for you, but remember everyone’s situation is different and the solution isnt always “i found a lawyer”.