So very frustrating...and you are already worried and tense. I hope you find that everything is in-network and that your husband’s surgery and recovery are problem-free.

I thought it was okay to go out of network in an emergency situation ... ?

Thank you, Fun! It's my son, not my husband, just to clarify. He's 18.

Jelly, I hope so! I've heard horror stories. And with the delay from his diagnosis tonight and surgery in the morning, I hope it's still considered emergent surgery!

What state are you in? Cali has laws preventing out of network charges for emergency treatment. It may be the case in your state, too. Google it.

Jelly toast, thanks for remaining me to google my state's laws. It sounds like, in an emergency, he is covered. Although, he has his insurance through an out-of-state school. We will see how that plays out. I hope the hospital labels the morning's surgery "emergent" so that it is covered. I've talked to everyone about this so that it's on everyone's minds. (When my first DC was born, I actually watched the clock: a birth after 3pm got us a second night in the hospital. He's clocked at 3:00:15, I pointed that out to the person recording the birth, and I'm not kidding! No, I wasn't crossing my legs lol just checking the time!)

I'm concerned about the fact that he is admitted and not going in to surgery directly from ER. The surgeon was not available as she was at another hospital performing, yes, an emergency appendectomy.

Sending good thoughts & prayers for your DS's surgery!

And peace for you. How ludicrous that health care system is so indoctrinated with technicalities that we have to be worried about making sure all the "t's" are crossed and "i's" dotted rather than on our kiddos!!!

What really bothers me is, I shouldn't have to worry about this stuff. HMOs and PPOs are a big pain. When a person is concerned about health, they shouldn't have to worry about networks.

It's really unbelievable that the insurance company does not provide the policy information somewhere online for people who find themselves in this situation!

Even emergencies are subject to priorities and scheduling. It certainly isn't elective surgery at this point. That would be my argument and I'd be sticking to it. Press on the insurance, but most important thing is that he gets the surgery before things get worse and that it all goes smoothly. Take care of him and the rest will get worked out.

Don't mean for that to sound unsympathetic. I will never forget how I felt when they wheeled my little guy back to remove his tonsils. That's always your baby and I don't think it ever gets easier. But right now you are waiting and worrying and those dang folks who ought to be there 24/7 aren't -- or at least they won't pick up the phone. So I guess that's another way to look at what is an emergency -- if it needs to happen before they get back to the phone and answer it, that's an emergency. ;-)

Hang in there. Mom! Hope you get some sleep tonight (not that I think I would) and that all goes smoothly in the morning and for his recovery.

I am so sorry you have this added stress and worry on top of your son being sick. I would certainly argue it is still an emergency. Sending my best wishes for a quick recovery and full insurance coverage without a battle!

I agree with lascatx...emergent doesn't always mean immediate, it means it can't wait for regular scheduling but needs to be done asap. An appendix isn't going to wait for him to return to school in another state and see a doc, get on a surgery schedule. I don't think I'd be very worried, but understand your concerns.

Hope you both get some sleep tonight and when he gets through surgery he's feeling much better. Appendicitis is no fun!

Call the hospital and they'll give you the information you need. But being a weekend who knows if any insurance people are there.

If you have any problem with the insurance over this, on Monday morning you need to call your state's Insurance Commissioner. That's what I did when BCBS said we weren't covered for a big hospital stay, and they got on it that same day, called me back and said it was fixed, and it was. Then they had me file a complaint. :)

How is your son this morning? Sending good thoughts to him!

I read recently that a lot (most) of the ER doctors are neither employees of the hospitals nor are they in network. They are outside contractors.

Here's story about that.

First and foremost bpathome, I hope you son is ok and please do check in when you have an update.

We are still doing battle with ins and the hospital for an ER visit DH had last fall. He was at the doctor's office and she told him to go to the er which of course he did. He needed immediate IV antibiotics. When the bills start rolling there's one for a doctor who is out of network - the hospital in IN network but not all the staff. He was awake and aware the entire time and has no memory of this doctor at all and the billing is coming through PA (we are in NC) so he's convinced there's something really fishy. The difference in charges from out to in network is $9 on a $1,000 bill for just this invisible doctor. Our healthcare system is appalling.

Our healthcare system is just fine, it's the insurance system that's appalling! It used to be so simple, and fairly affordable. Now it's insane, and insanely expensive.

Thanks for all the advice to check with my state, Illinois. I learned that supposedly there are protections in place for using emergency doctors who are out of network. I've bookmarked the information!

I have requested the social worker today, as the admin/insurance offices here are closed, and hopefully she will help us be informed and know what questions to ask and what to have on hand when we call DS' insurance on Monday morning.

I'll call the state insurance board Monday morning, too, to double-check.

i just remembered, Monday is a holiday. I wonder which offices are open, and which are closed? Another thing to check.

GWers are the BEST.

Yes - it's the insurance system that is out of whack - thanks for the clarification.

Holiday weekend, oh that just figures doesn't it?!

"Our healthcare system is appalling."

"Our healthcare system is just fine, it's the insurance system that's appalling."

Mine are one and the same. My insurer is my healthcare provider is my pharmacy. It does make it simple to get care, but there is no one to argue with when you disagree with something because they are all-in-one and one for all.

What is so horrible is that you need to be an extra conscientious consumer when dealing with health emergencies here in the USA, and who has the skills, let alone the calmness, to do that under such circumstances?

I totally hear you BP. SO's company changed insurance carriers for 2018 and he can't get a straight answer from anyone in the company about what is and is not "in network." He has talked to the insurance company and the billing office of his doctor. With many of the oversights being lifted or on the chopping block, I think companies are testing the waters to see what they can get away with. SO is actually having to rethink much needed surgery since the difference for him between out-of-network and in-network is 16K. But there is not one single in-network surgeon in a 100 mile radius of where we live. I'm not even sure if there are any, that's one way to limit coverage--cover the procedure but then have no in-network doctors to do it! So it looks good on paper until you actually need the care! :(

pinkmountain, that is dreadful. What a racket! How do they get away with that???

BP, I hope your son was able to get his surgery done and that things are getting back to normal for you. It's frustrating to deal with insurance and in the middle of a medical crisis, it's not something you need to worry about. Hope he's healing and doing well.

This thread seems like a good reminder that we should get rid of our current system and go to the model of every other first world country.

i hope your son's surgery is over by now and he is starting to feel better. Appendicitis is nothing to mess with, so glad they diagnosed it quickly. I am so sorry the insurance is so difficult to figure out-seems to be par for the course.

Something to keep in mind for when the bills start coming in - it may well be the case that the ER doctors and anesthesiologists are not in network, even though they work at an in-network hospital. A lot of them don't bother to join any networks since patients don't really have a choice of whether to use them once they're at the hospital. I think it saves the providers a lot of paperwork if they don't join networks, but it doesn't necessarily mean they won't accept insurance payments as full payment.

So if you start getting Explanations of Benefits saying they're out of network, don't just automatically pay those bills. First, call your insurance company and emphasize that you went to an in-network hospital like you were supposed to and you did your part to stay in network. The insurance company may well reprocess those claims and cover those bills as if they were in-network.

There's no guarantee, but it's worked for me in the past without too much trouble so it's definitely worth a try before just paying up. I didn't get balance-billed either, so the providers accepted the insurance company's payment as full payment (I think I still had a copay, but no more than if they'd been in-network in the first place).

To add to what SilverC said, when you are on the phone with a billing clerk, make sure to get the name, record the date and time and take copious notes. I didn't do that once, and blithely thought that the amount of money the person told me my MRI would cost was what it would cost. They were 1k off! I never would have agreed to the procedure if I had known that. (Due to chronic urinary tract infections, I was being tested for urinary tract abnormality, which did not show up in the MRI). Later when the bill came, I did not have proof of that conversation.

FWIW, I believe the ACA law still caps out-of-pocket billing for services ( I know my insurance does), I don't think they've managed to scrap that 1 yet...

Thanks for the update bpathome. "More advanced than expected" sure sounds like an emergency to me, as does the fact that they did the surgery on a weekend when non-emergency surgeries are not normally scheduled. Excellent idea to turn off that thought reel in your brain for the weekend.

Bpathome, I’m happy to hear that your son is recovering. Sorry that I misread your original post and thought it was your husband.

Agree -- "more advanced than expected" means he was right where he needed to be and sooner is better than later. I am surprised that neither the hospital nor the insurance carrier have anyone available. but now that your son is on the mend, you can take your time hashing the insurance issues out -- if needed. Hope that won't be necessary.

Another thing: When I was taken to an in-network hospital in sudden excruciating pain, the pathologist on duty was NOT in my network and sent bills for $1400 to diagnose kidney cancer. The bill arrived while I was still in hospital! When I was well we protested and were told that either I or my husband should have asked if ALL my providers were in my network! What? I was unconscious, my husband was panicked, yet it was our responsibility to ask if everyone was in-network. Who knew? We never even saw a pathologist. I guess if we had asked and been told our in network pathologist was unavailable, I should have just died right then and there!.

When I was well enough we argued the point with the hospital, the insurance company, and the pathologist. It was finally determined to be "hospital error" and we did not have to pay the pathologist. It took months to get that result. Don't let them buffalo you.

I'm glad your son is recovering. Scary business, that.

Sheesh, your story makes me say, well, "sheesh!"

We won't be buffaloed. DH was on me on Friday night about the network stuff, thank goodness I found our state's statement on THAT, thanks to GW.

My own crazy insurance story: when one of my kids was born, I called the hospital beforehand to see what the standard fee for labor-delivery-postpartum might be. Of course they couldn't tell me. I asked the insurance company, they wouldn't tell me. Afterwards when I got the bill, some things didn't look right, so I asked for an itemized bill, and saw some things I HADN'T had, so I asked for an audit. The final bill came out to one penny MORE. Why? It's a pre-negotiated price. Well, if it's prenegotiated, why couldn't anyone tell me that? And what was with the one cent increase? Probably to pay for the audit. Oh, btw, you know that cute onesie the hospital gives you? Yeah, you paid for it.

Dear Bp, I am so glad to hear the surgery is over and was successful. That. the important part. You have had some good advice here re the in/out network issue and I hope it all helps. The fact that he was in a network hospital and the other doctors were in network should hopefully give weight to your argument.

Re the emergency issue, is the policy or cert consistent in defining what an emergency is? Is there ambiguity? If it is ambiguous, you could hammer about the lack of clarity and consistency. Do your circumstances almost fit the definition? As mentioned above, do keep meticulous records of phone calls you made, even when nobody answered. Record the exact times. Record the names of those with whom you speak. The insurer, hospital employees, provider people, etc.

Carefully read the words about the emergency aspect and if there are some blanks that need to be filled, please consdier doing them, even later-if it makes sense. It certainly sounds like an emergency to me.

Read the provisions about termination of coverage and being an active full time student, if that is a requirement. If he is 18, can he be covered on other family member's group insurance, even at this date past the first of the month--if that develops as a necessary thing. I say this bc I remember that there was a question of whether that particular school was the right fit for him. I know this aspect was not covered in this thread, but it may possibly be an issue-its best to be prepared. Was premium paid for January 2018? I am thinking out of the box and certainly hope that your claim is paid quickly and as fully as possible.--and that my words seem to be nonsense! Good luck.

These insurance horror stories are shocking and pathetic. Our lives are in the hands of people who are completely lacking in common sense! My DH had to have a procedure (PET scan, I believe) which required an injection of a dye as part of the procedure. We have a set copay for PET scans, so we paid it at the time of the procedure and that should have been the end of it. We later received a bill in the hundreds of dollars for the dye, even though the dye is part of the procedure and the procedure can't be done without it. I had to make dozens of phone calls and write multiple letters to get it straightened out and that took weeks. What a royal PITA. It is really so sad that when you already dealing with stressful medical issues, you are burdened with all this other ridiculous nonsense. Where is the common sense in having a hospital in network, but not the people who work in the hospital? Who's running this idiotic s*** show??

Westsider, thanks for your thoughts! His insurance is paid up for the year through his college. DH has his own business and he is the sole employee, so we are on individual insurance. DS' school insurance was a better price. I've kept track of times I called and when no one answered. Also that I've asked for the social worker at the hospital, but have not yet seen him or her. Trying to keep on top of things, since I can't find out anything until Monday...or maybe Tuesday after the holiday. Yet another thing I don't know, who's answering their phone on Monday?

Bpathome so happy your son came through surgery! Sorry to hear he had a more severe case. Best of wishes for his recovery. (And hope all goes smoothly with insurance)

I have heard that sometimes doctors will ask for second opinions and reviews for a hospitalized patient, and one is billed if that second doctor is out of network.

Good that you are recording everything. Thanks for the info. I hope that he has a short recovery and continues to do well. Best regards.

In my previous job, a doctoral students's fiancee had to have an emergency appendectomy with student insurance when she was visiting him in our college town from out of state. She wound up at the for-profit hospital in the nearest city and then they had a several thousand dollar balance. Her parents and grandparents negotiated it down and then just paid it for her.

Gsciencechick, I drove my uninsured brother to the best hospital in the city when he had a cardiac issue. At every step, we let them know he was self-employed and uninsured. He had fantastic care over 4 days. In the end, he paired nothing. He is now on ACA (Medicare would have required him to go to subpar hospitals).

Well, the insurance company was also closed on MLK Day, so when I talked to them Tuesday, the hospital had already contacted them. What happens with the surgeon's bill depends on how it is billed. Sheesh. But at least they say that the dye for the contrast CT is covered!

DS is STILL in the hospital a 6th night! He has an abscess that they are now draining and treating. He's a real trooper. We spend all day doing all the puzzles in my old Games magazines that were too hard for me, then we watch Jeopardy (at 3:30 here). I realized that I need to do more logic puzzles, I used to be pretty good at them but I've let my brain slack off. But at least I'm getting up early. Doctors make their rounds about 7:30!

Hopefully he's home Thursday.

On the selfish side, I need to get back to healthy eating. The hospital room service is WAAAAY better than the cafeteria. I asked my son to order a mac-n-cheese side dish today so *I* could have it! it's amazing. DH came with dinner tonight, I told him I wanted a salad because I haven't had vegetables in 4 days. He came through! No dressing, just crisp, crunchy, and refreshing, just as I like it. When my dad was in another hospital in the same system for 2 weeks back in August, their cafeteria was much better.

"What happens with the surgeon's bill depends on how it is billed."

Are they going to cover it regardless due to the fact that it was an emergency?