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Wednesday, October 2, 2013


Photo courtesy of Samm Cox via Creative Commons; some right reserved.

In late July this summer, I hit the floor--throwing up.  Now this is an event I wouldn't usually choose to share publicly.  Bear with me.

After wet towels, a failed attempt at using a  ten year old suppository drug for nausea (yes, my bowels had joined the circus), and several hours of said event:  me, unable to get up, shaking uncontrollably, and with no signs of bodily control forthcoming, I begged my befuddled hubby, Earthman, to take me to the emergency room.

We arrived at the newly constructed Baptist Emergency Hospital in under ten minutes.  This is the hospital we trusted.  This was our hospital of choice. This was the CLOSEST hospital.  

As I could barely speak, Earthman asked the receptionist, "Do you take Blue Cross Blue Shield?"  This is the name of the company to whom we pay almost $2,000 per month for health care coverage. We have a PPO, which means we can choose our preferred provider from the insurance company's list of in-network providers without asking permission from a primary care doc.  We also have a $2,500 annual deductible for each of us.  I never meet this deductible.  This expense equals approximately $29,000.00 annually out of our pockets.

I cannot say enough good here about how quickly and carefully the nurses and doctor on call helped me to feel better.  After I'd given blood for routine lab work, urinated in a cup, answered a hundred questions between gags (do you know when you had your last tetanus shot?), absorbed two intravenous bags of normal saline and some very effective anti-nausea meds into my bloodstream, used every warm blanket they had in the warmer, and tried to keep the violent chills that assuaged my body from levitating me off the gurney for several hours, Earthman drove me home.

Thirty days passed.  The familiar "explanation of benefits" from our beloved insurance company came in the mail  I'm thinking, Betcha I met my deductible this time.  Wrong.  They had processed my claim as though I'd received services from an out-of-network provider.  The amount "I might owe the provider" line read:  $6,851.37.


Here's the point:  we had failed to ask the receptionist the right question.

The question all of us must remember to ask and tell all of our family members to remember to ask no matter what crisis or emergency we are facing is this:  


I picked up the phone and dialed Blue Cross.

Claims Rep:  "It's all about the codes.  See?"

Me:  "Well.  No.  I was throwing up my eyeballs."

Claims Rep:  "Because they are so new, the provider you chose did not file and become an in-network provider until three days after your visit."

Me:  " Isn't there a way to grandfather this visit in?  Remember how we used to change our grades from a C to a B?  Just takes an eraser and some balls!"

Claims Rep: "Ask the hospital billing department if they have another provider number under which they can submit this claim.'

Me:  "Huh?"

Claims Rep: "Plus they did not classify your visit as an emergency."

Me:  "It's an emergency room.  It says Emergency Room in bold, cobalt blue, neon lights right on the side of the building.  Plus, IT WAS AN EMERGENCY!"

And so the conversation went with the claims rep and then the same with the hospital billing rep who was quite helpful and finally understood that I was suffering from a pronounced panic attack and needed her immediate attention.  She agreed to appeal the claim and would talk to the codes person about what codes they could use instead that would change the outcome of my "explanation of benefits."

I don't know how it worked, but it did.  I now owe the hospital roughly $850.  I'll have to finance this stomach ache, but I'm okay with that. 

Here's what is not okay: that the emergency room intake person did not instantly say, "Yes, we do take Blue Cross but we are not yet an in-network provider" and further explain what that would mean to us before they offered me treatment, further giving me directions to the nearest in-network provider emergency room.   Also not okay:  that the insurance codes are not clear and can be manipulated and are so nebulous in their interpretations so as to potentially cost me $6,000.00.

The fine print:  all of this is my responsibility to know.  When I am well and before I seek treatment, I am supposed to read every term and condition (how many times have you clicked "I agree" without reading these?) of every policy I own or contract I sign.  In this case, I am also supposed to make a list of preferred in-network providers and hang it on the frig with my list of meds or carry it in my purse and then when I am deathly ill and perhaps my caregiver is beside himself with worry, I am supposed to remember said lists.

Okay.  Will do.  God forbid I'm unconscious.

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