I cut my hand open climbing in northern New Mexico, bandaids and gauze weren't stopping the bleeding, so I went to the nearest town clinic/urgent care. Ultimately got 8 stitches.
My insurance denied (almost) everything. They would later explain that I was supposed to drive myself several hours to Albuquerque to get my hand looked at instead.
I say almost because the covered $70 for the lidocaine shot, but literally nothing else. Why they deemed the lidocaine necessary but not the stitches could not be explained. Clearly they had a way to pay the clinic, so wasn't that.
Another whacky thing I discovered: the insurance company gets to decide how much, if any, of your uncovered, out-of-pocket bill counts towards your deductible. In this case they deemed $109 of $832 to be the right number, with no explanation as to how they arrived at that sum.
Ot is even possible for German citizens living abroad (I think outside the EU) to pay into a special insurance to maintain the German health insurance. Around 100 bucks or so, but I would have to read up on it again. Which is nice, e.g. because you travel full time or are an expat (the US comes to mind).
Edit: That's one provider, the 1 year plan is 35 Euro, ythe 5 year plan 59 per month.
https://www.hansemerkur.de/langfristige-auslandskrankenversi...
EDIT 2: Including the US and Canada prices increase by roughly 3 fold.
ER visits for emergencies are also covered as in-network care under the ACA, even if you're half way across the country. I know cuz I was 1500 miles into a road trip when I went to the ER. My insurance covered it as in-network.
https://arstechnica.com/science/2021/06/biggest-health-insur...
> Doctors and hospitals are condemning plans by UnitedHealthcare—the country’s largest health insurance company—to retroactively deny emergency medical care coverage to members if UHC decides the reason for the emergency medical care wasn’t actually an emergency.
Multiple attempts on my part to resolve this yielded nothing. I contacted the state of TX, who brought suit against both parties (insurance & service provider). Somehow, the day before the court appearance they all agreed to settle the claim at no cost to me.
Thankfully the bill I did receive was somewhat reasonable, and I was able to pay it without much issue.
So the insurance is saying "If you paid $80,000 for a medevac, we would have covered your hospital bill".
As for saying you should have driven hours with bleeding you couldn't stop--do you have any sort of appeal process? That certainly doesn't sound right.
An urgent care might not count.
Not that I think much of the likelihood of success, but aren't you, for any such decisions, entitled to (a) receive a justification on request, and (b) appeal that decision?
Hours, literally, of on-hold time, likely more than once, and if you're trying to get them to pay for something they don't want to, you're likely going to need to get state regulators or lawyers involved, which means even more time (and money, in the latter case). Probably you'll end up having to do the same thing with one or more hospitals or healthcare providers, playing go-between with them and insurance, and usually those places subject you to the same malicious-incompetence as the insurer does.
Not sure how plausible that is though--I suppose they could data-mine frequency of follow-up treatment required per doctor--but I've never observed in network/out of network to correspond to a meaningful metric (our local dentist recommended by all the dental specialists around doesn't deal with any insurance companies, while the in-network dentist is pretty clearly padding their work)
If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. If there's reason to not trust Dr. Nick, then surely Dr. Nick would have trouble maintaining a medical license. If there's reason to not trust Dr. Nick then surely Dr. Nick's own malpractice insurance would become too onerous for him to keep.
No, this smells exactly like what @Someone1234 stated:
> Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.
That should include "we think Dr. Nick makes fraudulent claims"
When insurance companies sign up doctors to their network, doctors agree to lower fees (lower profit) but expect to make it up in volume, because the health plan will send them more patients.
But that only works if patients are made to stay in-network, which produces the guaranteed volume. So health care plans won't pay if you go out of network. The economics would fall apart otherwise -- plans wouldn't be able to negotiate the lower prices because a doctor's office wouldn't see any uptick in volume.
Now it depends on the plan, but there are often exceptions for when you're traveling and need emergency care -- they'll pay network rates toward that because it's not a visit that an in-network doctor would have lost.
Also, plenty of "gold-plated" plans will cover anything out-of-network as well -- because they're expensive plans they're willing to pay doctors more, and so don't need to provide doctors with volume.
When it's a third party HMO network and you've got stuff like a medical office where only some doctors are in network and others aren't, so if your doctor is behind or out sick and you're offered to see another doctor in the interest of time and then you've seen an out of network doctor, that's a totally different deal. Then you've got things like in-office X-ray analyzed by an off-site radiologist whose identity and network status wasn't known before hand.
I'd like to see non-emergency medicine take up the same kind of quoting requirements as auto repair. You can't always stop a procedure to update the quote, so provide several quotes for the likely outcomes.
The out of network provider in an in network hospital is probably the most perverse thing to happen. One could be unconscious at a hospital and have out of network provider Dr Smith LLC stop in for a few minutes and send you her own bill.
$40/hr payout for physical therapy + translator contactor.
At least all the insurance I’ve had will pay using some formula like “we will cover 80% (instead of 90%) of charges up to the allowed amount (what an in-network would receive”.
The issue is that many providers balance bill, so everything above that is billed to the patient and since some negotiated rates are 50% or less of charges, the patient can own more than the insurance.
Basically insurance and providers fuck over the patients together.
Let's say you get a hypothetical procedure. Insurance has already agreed to pay in-network providers between $1-3K for this procedure. But you got this procedure out-of-network. Why is insurance's liability suddenly $0 instead of whatever the lowest in-network fee schedule would be ($1K in this example)?
See I can understand insurance not wanting to foot substantially higher bills than in-network providers charge, but I cannot understand why it drops to $0 reimbursed when you leave network. It seems like an immoral "gotcha."
But then again I'd like to see insurance discounts/agreements banned. Make everything and nothing in-network and also normalize the insured/uninsured prices. No more "$100 for a band-aid, -$99 discount" shenanigans.
Obviously single-payer would be better yet still, but if we must keep using this broken private employer-linked insurer system let us at least keep band-aid fixing it until we can get enough political support to scrap it.