Complications and ins

I ended up having a small complication with scar tissue forming in and around my bowel.  While the surgeon and staff were great about getting me taken care of I am now stuck fighting the ins company to pay for the surgical procedure that was needed to correct the problem.  My original surgery wasn't covered and I had to sell my only valuable asset in order to come up with the thirty five thousand that my RNY cost me so now I'm flat broke facing a multi thousand dollar hospital bill.  Has anybody else been through this?  What advice does anyone have for convincing my ins that this was very much a necessary procedure 

Have you engaged a patient advocate or ombudsman at the hospital?

Is the insurance not covering it because they don't believe it's a necessary procedure?  Or because they don't cover WLS and therefore don't cover any related complications, either?  Because those are two very different things.

When I fractured the root of a tooth last fall, my insurance would not pay for the dental surgery required to remove the broken piece of tooth.  That's not because they didn't think it was necessary to remove it, though.  It's because they don't cover dental surgery.   Since I did not purchase insurance that covers dental surgery, I had to pay for it myself.

If it's just that they don't think the procedure is necessary, have your doctor provide documentation that it is.

If it's that they don't cover anything related to WLS, then you're probably not going to be able to get them to cover it.

Go into the ER with severe pain and have them admit you.  It will be considered an emergency procedure, and will most likely be covered.  Good luck!  I hope you feel better!

Number one, the OP already had the problem fixed.  THe issue is payment for the procedure.

Number two, going to the ER with alleged severe pain will likely only get someone a  single dose of pain meds and sent home, NOT admitted to the hospital (even if there IS something wrong, unless the ER can pinpoint it and it is life threatening, they will not admit you).

Number three, if her insurance policy specifically excludes any payment for services as a result of a non-covered WLS, the insurance company STILL isn't going to pay for it regardless of whether she went through the ER or not.  The policy only covers what the policy covers.  period.

Lora 

Number one, I misread that part

Number two, that's 100% unbelievably false.  If you need a surgery to cure the problem which ails you, you will be admitted.  I know this for a fact.  I work for an insurance carrier.  Also i have been admitted to the hospital on two separate ER visits . Once, my insurance had not approved my gallbladder surgery yet.  I went to the ER with pain, and they admitted me and i had my surgery later that morning.  So i'm not sure where you're getting you're info but you are wrong.  I've also been admitted for an ovarian cyst.  He asked me if I wanted to be discharged with pain meds and f/u with my PCP.  I said no, I want to be admitted.  He said ok, and I was admitted.  All you have to do is advocate for yourself.  People are admitted into the ER on a daily basis for all kinds of procedures and then it becomes an emergency procedure and the insurance MUST cover it.  

Number three, If it can be caused by anything else, she can appeal their decision. And once again you're wrong.  If you are admitted into the ER for a procedure on an emergency basis, your policy covers all emergency services.  So I'm sorry but you're wrong.  

*Source - I work for an insurance carrier, am intimately familiar with the process, personal experience and research of my own surgeries*

If the ER determines that you need surgery, as in the case of your gallbladder, of course they will admit you, but MOST of the time, especially with abdominal pain, nothing shows up on a CT or ultrasound or in the bloodwork, so all the ER does is determine that you don't have anything life threatening, give you something for pain, and send you home to follow up with your own physician or surgeon.  THAT happens all the time!  All one has to do is read posts here to see how often people go in with some kind of abdominal pain, the ER sees nothing, and they are sent home.  I did that FOUR times before my surgeon agreed to do a (non-emergency) exploratory surgery (and found that scar tissue was binding my intestine to mesh from a hernia repair). 

I will concede that perhaps things have changed and that any service provided by an ER would be covered by insurance, but I know for a fact that 9 years ago that was NOT the case.  If you went to the ER for treatment for a complication from an elective (in this case, cosmetic) surgery, if it was not a life threatening condition, insurance was not obligated to cover it.

Ohhh I see what you're saying now but if you know what's wrong with you, that's a different story, I would hope!  Yeah if they can't determine what's wrong with you, I guess that would be different. But i can't believe you are in excruciating pain and they consider it non emergency! I think pain is the #1 reason to admit someone for a surgery! What if what you had was life threatening?  I guess we digress anyways because she already had the procedure done.  What insurance carrier do you have OP?  I can try and do some research for you and see if there is a way to get this paid for.  

Yep, people have trouble all the time with severe abdominal pain that they find no immediate cause for, and the ER just gives pain meds and sends you home.  They do, of course, do the CT to rule out things like a bowel obstruction and do bloodwork to rule out things like pancreatitis, but there are a number of things that don't show up on any of those (that do eventually require surgery to find and fix).  

With respect, I must disagree with you on your second and third points.  I'll reference EMTALA Regulations pursuant to 42 CFR sections 413,482, and 489 (as adopted by CMS final rule 1063F, 2003), to discuss the points.  

First off the definition of "emergent condition", while heavily influenced by the "Prudent layperson" rule, is still limited.  Pain as perceived by the patient does contribute to this rule (and is specifically indicated in the rule), however it only speaks to the applicability of the stabilization cause.  Speaking to the stabilization clause, the receiving ER is only required to stabilize the patient to the point that their actual life is no longer in danger until such time as an appropriate determination can be made.  The definition of stabilized speaks specifically to the state as well as the certifier of said state- in particular that only a medical professional approved to make such certification (usually an RN, NP, PA or MD) must confirm that ( I plagiarize here from section A406 of the regulation as posted in the federal register):

"Emergency medical condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or
symptoms of substance abuse) such that the absence of immediate medical attention could
reasonably be expected to result in:
          o Placing the health of the individual (or, with respect to a pregnant woman, the
                   health of a woman or her unborn child) in serious jeopardy;
          o Serious impairment to any bodily functions;
          o Serious dysfunction of any bodily organ or part; or
          o With respect to a pregnant woman who is having contractions:

               
                  -- That there is inadequate time to effect a safe transfer to another hospital
                       before delivery, or
                  -- That the transfer may pose a threat to the health or safety of the woman or
                       the unborn child.

Psychiatric hospitals that provide emergency services are obligated under these regulations
to respond within the limits of their capabilities.

Some intoxicated individuals may meet the definition of "emergency medical condition"
because the absence of medical treatment may place their health in serious jeopardy, result
in serious impairment of bodily functions, or serious dysfunction of a bodily organ. Further,
it is not unusual for intoxicated individuals to have unrecognized trauma."

NOTE:  These regulations, posted with an accepted 6th grade reading level as approved by CMS, current, must be posted in every treatment room of the ER facility in every language spoken by the surrounding community in excess of 5% by census volume.  Basically, these rules are everywhere. -michaelw

In this case pain is a contributor is but NOT a primary certification criteria. Assuming that stabilization is necessary, the facility is obligated to stabilize the patient (including ameliorating the pain condition).  They are not required to admit, to provide surgical services, or to provide any after-care beyond the stabilization care. In short, ****rogirl is 100% correct. 

Another critical point in this entire discussion, which I don't think you've appropriately captured, is that while EMTALA and subsequent state regulations adopted by NAIC do speak to the potential requirement of the medical PROVIDER to provide care, at no point does EMTALA codify (or even suggest a structure for enforcement) the requirement for any INSURANCE CARRIER to cover such care.  In fact, both state and federal entities have consistently (through several legal battles subsequent to and following ACA implementation) declined to establish this requirement. It is one of many bones of contention for providers.  Actually the only real clause within EMTALA that is instructive to carriers is the authorization prohibition clause (preventing carriers from delaying stabilization services by requiring an authorization).

Now, in support of your position, most carriers have historically covered ER services.  These generally have deductibles and or copays applicable, both of which will diminish the financial offset the OP is hoping for.  Further, many carriers also have a well posted "True ER" clause in their evidence of coverage that specifically speaks to a combination of both causative factors as well as diagnostic criteron as the basis of coverage. Pain alone is unlikely to drive a favorable determination in this case.  However if the scar tissue is likely to cause of exacerbate an otherwise covered condition they will likely consioder the ER visit covered, and in fact may cover the surgery to correct it as well.  However that surgical coverage determination will be well past the point of stabilization and simply returns her to the point she's at now. 

Further still, depending on the conditions of the causation of the scar tissue, they may determine the issue is simply one of third party liability.  This may happen prior to or following payment of the claim (or even authorization of the service) and thus will be subject to subrogation in all cases, especially those in which malpractice of the original out of network, non - covered service is alleged (the allegation can be made by the insurance company as the financial power of attorney and primary lossee. 

All of these statements are proven out the a detailed understanding of both the EMTALA regualtions as well as the adopted NAIC regulations prior to 2014.  Upon adoption of the ACA policy standardization rules in 2014, some of the rules are less flexible, but at this point none of these rules have yet been tested in any way legally, and very few of the salient points are even really affected by the law anyway.

All of the entire argument still is based on a series of assumptions that the original poster hasn't weighed in on (and I wouldn't even expect them to know as a prudent layperson, in fairness).  These include - presentation at an EMTALA covered facility, coverage by an appropriate policy (remember, ASO/TPA/Church Plans/and certain excluded entities have an entirely different set of rules that are WAY less comprehensive and restrictive in terms of coverage minimums), and the actual medical condition to be presented with. 

So, with all of this said, I'll make my recommendation. This recommendation is as an insurance professional, and not a medical professional and is NOT medical advice:

Get treated consistent with your surgeon's recommendations.  Get a second opinion if necessary.  Speak to everyone about getting the insurance to cover it.  If you exhaust that capability, start talking to people about cash discounting (most surgical coverage is 30% or less of billed charges, that's a great target in negotiations).  Talk about payment plans, credit cards, and alternative financing means. If you cannot get a good financial answer, you may want to consider surgery out of the country in a more financially advantageous location.  Regardless, do not let your financial woes cause more serious medical ones.  You can end up saving a penny and losing your life over it. Either way, remember that the ER is the single most expensive place in teh US to receive any kind of care, and the least likley to have pricing flexibility.  I discourage their use unless you truly have a real emergency. 

Finally- the OP made no mention of pain in any way in her post.  Lying, in addition to being morally corrupt, in this case is legally actionable and defined as the way you've recommended it as "intent to defraud".  I would discourage it. 

As you've indicated your source, I will as well.  I am an insurance executive with over twenty years serving members in plans as small as 100K and currently as large as 2.5MM.  I've served as a legal compliance support analyst in federally sponsored MA/MAPD products, ASO/TPA. Commercial employer sponsored, State medicaid sponsored, individual (pre and post ACA plans), and catastrophic policies.  I'm licensed in six states for life and health, as well as a recognized compliance professional for both medicare and medicaid products by CMS.  I currently serve as lead of an advanced finance and clinical analytics group for a fortune 300 carrier, and regularly consult in benefit design, claims adjudication, and clinical appropriateness determinations.  In past roles I've worked the claim shop, config, provider support, and special investigative units.  Prior to this, I worked clinically as a medical technician with my most relevant role as a discharge planner for a level 1 trauma center in a 550 bed hospital.