Out of Network question

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My son had an accident and we took him to the closest emergency center

Some stitches were done on his head and since this was emergency BCBS treated as IN NETWORK. But on file this was an out of network facility

10 days later Emergency room calls us to make an appointment to take the stitches out. We went back to ER and they took the stitches out
I received a bill for $500. So I called BCBS and they said I should have gone to my regular physician for removal of stitches since this can be done by anyone

It turns out, ER recorded the visit as non emergency which is right, but how would I know?

I want to appeal this and I need some help in writing a letter to appeal and dispute $500 charge . Any suggestions?

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Be happy it was only $500.
Who goes to the ER to get stitches taken out?? It's designed for life-threatening emergencies.... (more)

canoeguy1 (Dec. 28, 2016 @ 10:57p) |

If you live in an area with an aggressive "Family Services" and you do not obey hospital orders for your child, good luc... (more)

JiggleTheHandle (Dec. 28, 2016 @ 11:15p) |

If you have a question about benefits or In/Out of network best thing is to call your insurance company and ask them. Pe... (more)

Geokuk77 (Dec. 29, 2016 @ 12:52p) |

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What was done is completely correct and legit. What exactly are you appealing?

Asking the facility to re-code as an emergency visit? They can't, it was not.

You could try the route of appealing to your insurer to pay more than OON benefits, but with BCBS, good luck.

tennis8363 said:   What was done is completely correct and legit. What exactly are you appealing?

Asking the facility to re-code as an emergency visit? They can't, it was not.

You could try the route of appealing to your insurer to pay more than OON benefits, but with BCBS, good luck.

  I understand it is legit but as a parent you have been called to come over and they will take the stitches out
How would I remember or know that I should avoid ER again. How someone stay alert for all these things?

I guess I have to suck it up

fleetwoodmac said:   I want to appeal this and I need some help in writing a letter to appeal and dispute $500 charge . Any suggestions?
This stinks, but I think the insurance company is right. The original incident was an emergency, but the follow-up wasn't.

I would still do an appeal letter, saying that you thought it was most prudent and medically necessary to have the same facility remove the stitches as put them in, since they were familiar with your son's condition and care. (but you are facing an uphill battle here)

The hospital should have sent you to your physician, not asked you to come back to them. I'd negotiate with the hospital, perhaps even escalating to their executives, and ask them to take the $80 or so the PCP would have gotten for this service.

BrianGa said:   
fleetwoodmac said:   I want to appeal this and I need some help in writing a letter to appeal and dispute $500 charge . Any suggestions?
This stinks, but I think the insurance company is right. The original incident was an emergency, but the follow-up wasn't.

I would still do an appeal letter, saying that you thought it was most prudent and medically necessary to have the same facility remove the stitches as put them in, since they were familiar with your son's condition and care. (but you are facing an uphill battle here)

  Thanks I will put that in the appeal

doveroftke said:   The hospital should have sent you to your physician, not asked you to come back to them. I'd negotiate with the hospital, perhaps even escalating to their executives, and ask them to take the $80 or so the PCP would have gotten for this service.
  Thanks. I will call them and tell them this
Just to let you know this was a stand alone ER not a part of an hospital but nevertheless they should not charge this much.

I haven't had stitches in decades but don't they just dissolve?

atikovi said:   I haven't had stitches in decades but don't they just dissolve?
  He was only 1 year old , I did not want to risk anything

I say thank God your son is okay, doctors took good care of him, pay the bills and move on.

Try appealing if you want to but unfortunately it is more of a waste of time, not to mention the headache that comes along with it.

Don't be surprised if you get a bill from the hospital or treating physician for putting the stitches in. Even though your insurance covers it as in network, there is nothing stopping them (save a few states) from going after you for the difference between the reimbursement and the amount billed.

fleetwoodmac said:   
atikovi said:   I haven't had stitches in decades but don't they just dissolve?
  He was only 1 year old , I did not want to risk anything

  My mom used to cut off my stitches.  I always thought everybody parents did that.

JepJepJep said:   
fleetwoodmac said:   
atikovi said:   I haven't had stitches in decades but don't they just dissolve?
  He was only 1 year old , I did not want to risk anything

  My mom used to cut off my stitches.  I always thought everybody parents did that.

  Sorry for the misinfo

It is not stitches it is like stapled. First time I have ever seen. There is no way I could have taken those out

Emergency room usually gives you written instructions for follow-up along with any prescription for medication at the time you leave the ER. Did it say to return to ER or to go to your physician?

fleetwoodmac said:   It turns out, ER recorded the visit as non emergency which is right, but how would I know?
You started the following thread almost a month and half ago:
How to prevent out of network people away from surgery room?

Based upon the experience your "friend" had in that other thread, it's dumbfounding that YOU of all people haven't learned to verify insurance coverage EVERY TIME before proceeding with ANYTHING medical related (if possible). Obviously if it's an emergency situation, you may not be able to do that (as you may be unconscious, incoherent, dead, etc.)

I get your logic about why you felt it would be best to take your son back to the original facility, but if you had done some basic due diligence by asking whether the stich removal procedure would be covered by your insurance, upon being told NO, it's likely that you would have learned about other options.  Why?  Once you're told that a procedure is NOT covered by insurance, a smart follow-up should be to ask WHAT OTHER OPTIONS ARE AVAILABLE to you. At that point you would have likely been informed that the procedure can be performed elsewhere (at places which DO accept your insurance for non-emergency purposes).

*EDIT* Grammar

TheDiggler said:   
fleetwoodmac said:   It turns out, ER recorded the visit as non emergency which is right, but how would I know?

You started the following thread almost a month and half ago:  How to prevent out of network people away from surgery room?  

Based upon the experience your "friend" had in that other thread, it's dumbfounding that YOU of all people haven't learned to verify insurance coverage EVERY TIME before proceeding with ANYTHING medical related (if possible).

  
Also, you (fleetwoodmac) asked a question about out-of-network billing yesterday, in my new thread on the subject (it was the 2nd post in this thread:  https://www.fatwallet.com/forums/finance/1548922 ),

and I suggested that you have a look at the "How to prevent" thread to learn more about the issue...
because I didn't realize that you had actually been the person who had started that thread a month and a half ago! 

...There was so much helpful information (and further links) given by others to you in that "How to prevent" thread.

------
What is an emergency room that is not attached to a hospital (which is how you described the emergency room that treated your son with the Staples)?  Was it a walk-in / urgent-care clinic?

oppidum said:   
TheDiggler said:   
fleetwoodmac said:   It turns out, ER recorded the visit as non emergency which is right, but how would I know?

You started the following thread almost a month and half ago:  How to prevent out of network people away from surgery room?  

Based upon the experience your "friend" had in that other thread, it's dumbfounding that YOU of all people haven't learned to verify insurance coverage EVERY TIME before proceeding with ANYTHING medical related (if possible).

  
Also, you (fleetwoodmac) asked a question about out-of-network billing yesterday, in my new thread on the subject (it was the 2nd post in this thread:  https://www.fatwallet.com/forums/finance/1548922 ),

and I suggested that you have a look at the "How to prevent" thread to learn more about the issue...
because I didn't realize that you had actually been the person who had started that thread a month and a half ago! 

...There was so much helpful information (and further links) given by others to you in that "How to prevent" thread.

------
What is an emergency room that is not attached to a hospital (which is how you described the emergency room that treated your son with the Staples )?  Was it a walk-in / urgent-care clinic?

  this was a walk in ER stand alone building and have no affiliation with any hospital

It is a chain network. It is very close to my house

So this is what I will do today

1) Call the company that owns the ER, try to get in touch with some official and present my case. (no hopes) 
2) Write an appeal letter to BCBS (no hopes here either but free to try)

something I learned yesterday
out of network charges does not count towards deductible and out of pocket maximum

OP: Please be sure and start a few more threads about this same topic, ok?

"She is way out your network"

I assume you have a phone. Since you knew the place was out of network why didn't you call insurance company and see how to get further treatment. Would have taken less time then your spending now trying to get out of the bill. Can't believe how many people just assume all will be taken care of. If it would have happened on a vacation would you have returned there to get the stitches out. Am sure you would have called insurance company to find out what to do next. Would say get with the program and see how things are covered. It is your responsibility to know your coverage.

Be happy it was only $500.
Who goes to the ER to get stitches taken out?? It's designed for life-threatening emergencies.

On the other hand, why would an ER call you at home to ask you to come in and have this procedure? Very odd.


ER Prices often start upwards of $3000, just for putting your foot in the door. I've never heard of an ER bill as low as $500.
You may have more bills coming from various groups that helped with the procedure. ie the physician could charge you, the ER facility could charge you, etc etc.

fleetwoodmac said:   10 days later Emergency room calls us to make an appointment to take the stitches out...

If you live in an area with an aggressive "Family Services" and you do not obey hospital orders for your child, good luck.

Families is some places will be at risk if they do not obey.

If you have a question about benefits or In/Out of network best thing is to call your insurance company and ask them. People always try to figure it out themselves or look on the doctor's website or trust the hospital billing person...but none of them is paying the bill, your insurance is. They define your benefits and are the ones making contracts with the providers so they are the best ones to tell you what you should do and where to do it at. If anyone here should find themselves in a similar situation....go to the ER and while you are there in the waiting room, call your insurance and let them know your situation and ask them what you need to do. Then when hospital calls you back and tells you to go back in to them, call your insurance company and ask them what to do. They log all of their interactions with you and should know your benefits better than anybody.



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