When a HMO Won't Pay for a OON Emergency

[Northeast Agent]

There's an issue that I am just sick over. I did sales seminars last fall for a regional large MA carrier. During the presentation regarding HMOs, I told beneficiaries that you can't go out of network with an HMO, "unless it's an emergency." I wrote up an elderly couple on the plan afterwards, as their $0 premium Humana plan was leaving the area. The issue is when they went out of state in late January on vacation, and the wife had an attack of diverticulitis. She was admitted to the ER and kept overnight. The next day the carrier provided a verbal authorization to the hospital (with an authorization number), but now she is receiving huge bills and the carrier is sending letters, "claim denied," while the hospital is demanding payment.

I've been back and forth with my contact at the carrier, who says he is "working on it." I don't know what to do at this point - sit tight and wait a little longer, or help the client file a grievance before she takes further action? Also, if someone feels they are having an emergency but are unsure if it's OK to go to the ER, are they just supposed to not go, and end up in a lot worse shape?

I will NEVER sell another HMO after this, unless it's a carrier with an extended network, like Aetna or UHC (but their networks are very skinny here). I'm going to focus on Med Supps and Life now, and the PDPs I'll refer to Ritter's call center. Also if I do another seminar it will be educational only for Med Supps. I feel like during the MA seminars, you can't disclose everything, such as most plans cover physical therapy as a specialist co-pay. There are a lot of carriers and plans in my area, and only one of them has a PPO with $15 copay for both physical and occupational therapy. But everyone wants the $0 HMO with all the bells and whistles as they are never going to get sick (or end up in the ER) and not pay $159 for the PPO.

 

[GoPokes]

Go directly to CMS. I had an issue last week that I didnt know how I was going to resolve, the insurance co wasnt helping. So I did a 3 way call with medicare and the client, and by the end of the call I had the resolution I was seeking.

 

[horskj]

Exactly...go directly to CMS. per contract with CMS all HMO's provide in network coverage for an emergency. I would not let this one thing discourage your from marketing HMO's. They do have their place and tend to be a more benefit rich plan.

 

[somarco]

Read the policy language. Good chance the words "life threatening emergency" or something similar is there.

Note: non-life threatening "emergencies" are generally not covered by insurance, including Medicare

You may need to get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier.

Or else the carrier is being difficult.

 

[wehotex]

There's an issue that I am just sick over. I did sales seminars last fall for a regional large MA carrier. During the presentation regarding HMOs, I told beneficiaries that you can't go out of network with an HMO, "unless it's an emergency." I wrote up an elderly couple on the plan afterwards, as their $0 premium Humana plan was leaving the area. The issue is when they went out of state in late January on vacation, and the wife had an attack of diverticulitis. She was admitted to the ER and kept overnight. The next day the carrier provided a verbal authorization to the hospital (with an authorization number), but now she is receiving huge bills and the carrier is sending letters, "claim denied," while the hospital is demanding payment.

I've been back and forth with my contact at the carrier, who says he is "working on it." I don't know what to do at this point - sit tight and wait a little longer, or help the client file a grievance before she takes further action? Also, if someone feels they are having an emergency but are unsure if it's OK to go to the ER, are they just supposed to not go, and end up in a lot worse shape?

I will NEVER sell another HMO after this, unless it's a carrier with an extended network, like Aetna or UHC (but their networks are very skinny here). I'm going to focus on Med Supps and Life now, and the PDPs I'll refer to Ritter's call center. Also if I do another seminar it will be educational only for Med Supps. I feel like during the MA seminars, you can't disclose everything, such as most plans cover physical therapy as a specialist co-pay. There are a lot of carriers and plans in my area, and only one of them has a PPO with $15 copay for both physical and occupational therapy. But everyone wants the $0 HMO with all the bells and whistles as they are never going to get sick (or end up in the ER) and not pay $159 for the PPO.

Send a letter to Insurance carrier with details and cc: nearest regional Medicare office. Send a copy to the Medicare office too. Which carrier is causing you so much grief?

 

[GreenSky]

Read the policy language. Good chance the words "life threatening emergency" or something similar is there.

Note: non-life threatening "emergencies" are generally not covered by insurance, including Medicare

You may need to get into the weeds regarding diagnosis and treatment codes with the billing provider(s) and carrier.

Or else the carrier is being difficult.

If the insured believes it to be an emergency then the HMO is not in a position to question it. The carrier is just being difficult.

Rick

 

[sman]

I just looked in a carrier's EOC to see their wording. Here it is:

A "medical emergency" is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

In another section it has this Q&A:

What if it wasn't a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it wasn't a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care.

The carrier is likely going to lose this battle. It's unfortunate that it may come to filing a grievance/complaint with CMS in order to get them to follow the rules.

 

[horskj]

I just looked in a carrier's EOC to see their wording. Here it is:

A "medical emergency" is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

In another section it has this Q&A:

What if it wasn't a medical emergency?

Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it wasn't a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care.

The carrier is likely going to lose this battle. It's unfortunate that it may come to filing a grievance/complaint with CMS in order to get them to follow the rules.

what he said...

 

[sman]

what he said...

Did you just refer to me as a gender? Don't you know we aren't allowed to assume a persons gender anymore? According to these geniuses there are 63 genders.

https://apath.org/63-genders/


Hmmm, I wonder what the wage gap is among all those genders?

 

[BobbyMcGee]

As others have stated, file an appeal with the carrier and CMS. I am 6-0 on appeals/grievances in the last year, one similar to this. One of my clients just got a check today for "take home drugs not covered" except they are.
The "summary of benefits" is an excellent source for writing your appeal. You will win.