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rated:
Hey guys and gals, had a question about some recent medical bills I incurred. First, I am a male and am 30 years old. I am insured with Humana. I recently had severe problems breathing and was seen by 3 different ENT's who all said that nothing was wrong. I had a previous bout of throat cancer in 2013, so anything involving my throat worries me. Finally when I nearly stopped breathing I went to the E.R. and they did imaging which found a cancerous tumor that had almost completely blocked my airway. I was kept overnight and the next day I was sent by ambulance to the closest hospital that would see me since my situation was an emergency. The hospital was a 5 hour ambulance ride away from the E.R. in my town where I went. Well, long story short, Humana has denied my entire claim saying the E.R., ambulance ride and hospital where I was for 2 weeks having 2 separate emergency surgeries and recovery, were all out of network. I wrote an appeal stating the emergency nature of my illness, but they still denied it all. Well, I think they said that they paid their limit on out of network, which equated to just about nothing. I now have several hundred thousand dollars worth of medical bills. 

Does anyone have any suggestions on options i can pursue at this point? Any help would be more than appreciated. 

Thanks
Josh

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rated:
So what exactly is the point of insurance if it's not to cover you in emergency situations?

rated:
That's exactly what I thought and how I feel, and kind of why I was so surprised when they denied me..

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If it's an ACA exchange Humana plan, I can't imagine anything over 50 miles away being in-network, much less a five hour drive away. Such a flaw in our healthcare system. Were you supposed to negotiate with Humana on the phone to authorize the procedure while you were intubated with throat cancer?

rated:
Josh, there is no reason to put in your full name in your original post -- you might want to edit that from your post above.

Fatwallet threads are indexed in search engines, and you should guard your personal financial and medical information from being available to the wider public.

rated:
There are prior threads on Fatwallet about some of these pitfalls of health insurance, if you want to do a search here. (https://www.fatwallet.com/forums/search)

In the past few years, there have also been a number of good articles in the New York Times newspaper (www.nytimes.com) about this out-of-network malarkey that the insurance companies pull even when someone is having a health emergency, as well as some good articles on the www.KFF.org website.
I would recommend taking a few hours to read those articles and the reader comments.

I think there are lawyers who deal with this kind of situation -- you may want to turn to expert help at this point, since your bills are so high, and time is probably of the essence (to protect your assets and credit history).

rated:
By the way, the first appeal is just one step in the appeal process -- there are usually 3 levels of appeal. The final level is often to the ombudsman or government insurance commission in your state.

I don't know if you have already taken your appeal to that third level -- maybe you have -- but definitely explore every possibility allowed by your insurance contract.

(I have had to take an insurance appeal to the second level, and I won it, even though it had been denied by the insurance company at the first level of appeal.  It took about 9 months.)

rated:
Sorry to hear that you're going through this mess. It's bad enough being sick, but to then deal with billing is even worse. 

1) What does your schedule of benefits and plan say?

2) Have you appealed the claim? It might be helpful to consult your medical team and billing department to see if the claims were submitted correctly.

rated:
Thanks Oppidum, no I wasn't aware that there were three levels of appeal I could pursue. I will research how to pursue appealing further. And I will research some of the links you posted. Insurance is easily confusing. Never been insured until a year ago. I did speak with my medical team, but I might call them again to see if there's anything further they can do to help. I had thought about hiring help, but just wanted to make sure there weren't any easy steps I was missing first, especially since income has gone down not being able to work like I did before. Still working, but just more moderately.

Thanks for responses. Always find good help on this forum on all kinds of situations. 

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TravelerMSY said:   If it's an ACA exchange Humana plan, I can't imagine anything over 50 miles away being in-network, much less a five hour drive away. Such a flaw in our healthcare system. Were you supposed to negotiate with Humana on the phone to authorize the procedure while you were intubated with throat cancer?
  I just assumed that when they kept asking me for my insurance card and info that it must have been approved. Honestly, wasn't in my right mind to really care at the time. Wasn't sure if I was going to make it for a bit. So I'm not really sure if anything was ever authorized.

rated:
I have full sympathy for you OP.
The system is so f#$ked up that when you actually need it they will screw you over but are happy taking your money.
You should also explore the possibility of suing those 3 different ENT's who all said that nothing was wrong.

If all else fails they should not only pay for your bills but also for pain and suffering since their inability to diagnose your cancer early enough led to this.

rated:
Josh,

Health insurance is so complicated, illogical at times, and stacked against the consumer.

This kind of thing has happened to other people who had to go out-of-network for emergency reasons in the last couple of years, so you are not alone.

Some of them have won their fights for coverage, some of them have not (even when they had good advocates/lawyers).

You must immediately read your contract carefully, all 50-100 pages of it, and take notes on the relevant statements.
Towards the end, it will set out what the appeal process is.
You need to follow that official appeal process for your specific insurance plan exactly, because you can mess things up if you don't.
They will usually give the exact address and/or fax number for you to send your written appeal to, they will spell out the time frames, they will name the final arbiter, etc.

What I learned a couple of years ago is that you can't call their telephone customer service, speak to whatever person answers, ask them about doing an appeal, and believe ANYTHING that that random person says about your case. I had so many of the insurance company telephone customer service people tell me the wrong procedure that I should to follow, or pre-maturely tell me that my case had lost (when it had not).
They have no incentive to stick up for the customer at the expense of the company, and to explain the official procedure in great detail (which they probably have the wrong idea about, anyway).

You need to utilize the official appeal process fully, which can take a long, long time to finally come to a conclusion (months, or even years).

If that doesn't work at all, then with medical bills, there is usually a lot of room for negotiations and bill-reduction with the service providers.
You may get to the point where you are negotiating for reductions in your bills with your individual service providers.
Sometimes they will offer reduce the charges to a low percentage of the original charges, sometimes they will offer a long-term payment plan.
You may or may not want to do that simultaneously to making your official appeal to the insurance company (that is the kind of tactical decision that you should get expert, paid advice on, I think).

There are also some charities, churches, etc. that will cover some devastating medical bills for some people. I don't know much about that. These will vary by area of the country. You could look into it.

I know you said that you approached your medical providers once about giving you help in this. While they might be able to re-write the codes that they used to describe your medical treatment, or to better describe their decision to send you five hours away in an ambulance, it's not really their fight.
The service providers are not going to be fully on your side, because they must represent their own interests. The three parties in this are you, the insurance company, and the service providers, and all three have their own one-on-one tussles with each other. They are out for themselves at the end of the day because our healthcare/insurance system is relatively adversarial.

You might want to get your ducks in a row and do all the other research that you need to do before approaching the providers again. If you want them to help you, you'll need to understand what you want to ask them about your case, and what effort on their part might help you the most and cost them the least.

If you might have to consider bankruptcy, if you have student loan debt, they usually are never allowed to be part of a bankruptcy. You have to prove that you are permanently incapacitated/disabled, which you are not. If you go the bankruptcy route, you'll want a lawyer to help you through it.

Try to guard your credit record/score if you can, while this is going on. It may be impossible, and that is understandable, but at least be aware of the ramifications that this is having on that part of your life/future.
I think that a year or two ago, some laws were passed saying that credit scoring agencies can't use medical bill defaults and that kind of thing, but this is not my area at all, so you'll want to consult reputable sources about that.

Since you originally gave your full name and you have named the insurance company and described something very unusual (such a long ambulance ride, your repeated throat cancer at such a young age), if it comes to a lawsuit, they might be able to look this up on the internet and use anything you say here as part of their case.
So be aware of what you have already written (which is usually recorded by several organizations like Google, the Internet Archive, the government, etc., even if you remove it later from your posts), and anything further now that you might describe in detail.
You don't usually have to give specifics in order to get the kind of general advice that you can get from a site like Fatwallet.

I hope that you have found the relevant articles on out-of-network emergency insurance denials that I mentioned by the New York Times newspaper, KFF, and other reputable sites online. One can learn a lot from the reader comments on those articles, too, because people will relate their own stories and give tips that helped them.

Like a poster above, I wondered about the 3 different ENTs who, apparently just before your emergency room visit, had all told you that you had nothing medically wrong with your throat, yet you had a large tumor.... I am not a litigous sort of person, but depending on the exact circumstances, maybe you could have a case against one or more of them for fobbing you off without doing enough investigations (like imaging, blood tests for cancer markers, or whatever).

When you were receiving your emergency treatment, you were at their mercy and you had to follow their advice and decisions entirely, but it's hard to believe that there was no in-network facility or doctor within a 5-hour's-drive radius who could have helped you (unless you were not in your home city when this happened to you -- were you out of state?) Sadly, it's not the medical facility's responsibility to consider what your insurance would cover or not cover.

---
HOWEVER -- The great thing is that you have had your treatment and surgeries, and hopefully you are doing so much better now!

At least as far as the laws are right now, you will not face any financial maximum caps on lifetime insurance coverage/payouts that you can receive, and you will not be hit with a refusal to cover anything in the future that relates to your multiple pre-existing conditions, which five, ten, fifteen years ago you might have. These are not benefits that any of us can take for granted.

Best of luck to you.

rated:
hi Josh, well if they needed to go out of network did they tell you. or were you aware. was it a emegency procedure? there are states like NY thT IF THERE IS NO CHICE AND YOUR IN A EMEGENCY AT THE TIME THE INSURANCE WILL NEED TO EXTEND PREFFERED BENEFITS ON A CASE BY CASE OPTION  to provide for you but they will wait for you to file that form and make the case

rated:
TravelerMSY said:   If it's an ACA exchange Humana plan, I can't imagine anything over 50 miles away being in-network, much less a five hour drive away. Such a flaw in our healthcare system. Were you supposed to negotiate with Humana on the phone to authorize the procedure while you were intubated with throat cancer?
  
Depends on their network.  I've been in-network 2000 miles from home on an ACA plan.

rated:
I would contact the financial aid department of the hospital and ask for relief the the hospital bills, it will not cover the ambulance or individual MD bills, but most hospitals will write off the hospital charges if you can show financial hardship

rated:
Did the hospital that sent you 5 hours away call your insurance company to see if there was an in network provider or to get prior authorization? Unless extremely emergent they should have called your insurance. Is the hospital they sent you to the closest that could provide the emergent services that you required? What hospital was in network that could have provided the service?
The hospitals should have case Management departments that can help you appeal as well, since technically they are getting denied payment as well. I would go back to the sending hospital and ask them if they had any communication with your insurance plan before sending you and if not, why not.

rated:
get a copy of your policy and read it.

the insurance company will be bound by those terms - if they are not required to pay on out-of-network claims (and the costs incurred are truly out-of-network), then they are not liable to pay them and as any good capitalist free market corporation would, they will not pay them.

see if you can find a loophole.  if not, file for bankruptcy and discharge your debt if necessary or negotiate with the providers for a cash rate (typically up to 80% discount from the 'insurance rate'.

good luck.

rated:
dobz88 said:   Does anyone have any suggestions on options i can pursue at this point? Any help would be more than appreciated. 
What state are you in and what does your benefit plan spell out for out-of-network emergency cases? I ask because some states have rules in regards to being billed for out of network emergency cases,some don't, and many benefit plans spell out what happens for out of network emergency cases as opposed to just out of network volunteer type visits.

rated:
As others have said, review your coverage carefully. Specifically, check to see if there is an out-of-pocket maximum for out-of-network providers. For instance, my plan has a $15K out-of-pocket max for OON, so once I hit that mark, the insurance company starts paying.

rated:
Somebody else has to pay. Either the original doctors who mis-diagnosed you - at that point you wouldn't even have needed the Emergency Response that cost you, or the insurance which gladly accepts the premium in order to cover you in case of emergency. Unfortunately, you'll probably need some legal help...

rated:
First, as others have advised, carefully read your policy and print out and highlight salient features pertaining to emergency care, in-patient hospital care, surgical services, doctor services, laboratory services, and ambulance transportation for both in-and out-of network situations. Try to find the section defining how and when referral and transportation to another facility (in- or out-of-network) can be invoked.

Second, contact the financial department of both hospitals to see if they notified Humana upon your admission and received pre-authorization on your behalf. Most hospitals do this automatially. Do you remember speaking with hospital folks in the ER or after being transported to the other hospital and giving them your insurance info and signing consent to treat forms? These are the hospital folks from the department charged with contacting Humana. There will be a record of their contact with Humana, and Humana's response to them. Be aware that even if you originally spent many hours in the ER, you may have only been in an "observation" status and not actually admitted. It is much to the advantage of both hospitals to help you get Humana to pay, and they may well do so to keep from having to write off the whole bill. Also please be aware that the amount that the hospital (and all of the other providers) charges YOU is absolutely NOT THE SAME as the adjusted "contract" price that the providers charge Humana. This "adjusted" cost is much lower. Somehow our modern society has come to accept, condone, and even promote the appallingly dishonest and unethical concept of charging different folks differing amounts for the exact same item or service.

Thirdly, as others have already advised, initiate the appeals process. Be prepared to follow through TO THE LETTER at every level, and never give up or give in. You will be helping others in the same boat as well as yourself. Good will come of it all somewhere down the line, even if your process comes to a dead end.

Fourthly, once you have documented ALL the facts and have your ducks in a row, contact your state's Insurance Commissioner. Follow their advice EXACTLY as to possible further actions.

Fifth, you can consider seeking legal advice regarding potential liability of the three ENTs who did not accurately diagnose your illness. However, if they followed the guidelines of standard medical practice (standards of care), it will be very hard to prove a case. Pick your battles. If your goal is to punish them for failing to help you, then be aware that once you go after them, NO ONE will help you. If you just want Humana to pay your medical bills, then focus on that and you will likely get lots of help from the providers, who just want to get paid.

Finally, always take the moral and ethical high road, even if others take a different path. These medical folks and hospitals likely saved your life. If you can only pay a little and absolutely MUST file bankruptcy, then you have no other choice. Otherwise, if Humana never pays and all other avenues are exhausted, try to negotiate with the providers to a lower amount and make payments in good faith over time. Via Con Dios!

.
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...............................

rated:
With all respect and sympathy to this terrible situation,if you buy home insurance and don't get earthquake coverage then if an earthquake totals your house insurance does not pay.
If you go out of network your health insurance won't pay.

Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act. So the issue here is when did the emergency nature of the care stop. Once stabilized all other care is non emergency care even if it is still urgent or even dire. In this case the fact the person could stay overnight and then be moved in an ambulance for 5 hours would be evidence that the care was no longer emergency in nature although it was urgent. And that is why Humana is refusing to pay (i.e. he could also have take a 5 hour ambulance ride to a hospital that was in plan).

If in fact they did not pay for the original ER visit you have a legitimate issue with them and that may help you because not paying for the emergency portion is an egregious violation.

It is true you must follow the appeal policy to the letter. I would see if you can find an independent Medical Ombudsman to help you at every step. Because what you don't want is for Humana to pay for the first ER bill and nothing else. To that end getting representation early and argue that you were never actually stable and that you were also incapable of contacting them due to the nature of the illness.

Best wishes on your recovery.

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