Battling with my HMO

[Cirrus]

I just got off the phone for the 589,442,474th time with my insurance regarding a hospital visit I made about a month ago. The reason is kind of personal, but here's the short version of what's going on.

I went to the hospital, and the way our hospital is set up we have "urgent care", for when you're sick enough not to wait for a Dr. appointment but not sick enough for the ER, and ER reception at the same desk. There's a nurse at the desk that decides which you go to. I walked in and said I wanted to see the Urgent Care doc, and she asked what the problem was. After explaining what was going on, she decided I should go to the ER instead. Now my insurance won't cover it because they don't deam it an emergency.

Has anyone else had anything like this happen to them? What did you do? For the people with legal training, what are my options?

 

[Pokerman]

Try talking to someone in the hospital's administration. Often, they can intervene on your behalf.

We needed some stuff for my daughter once, and the HMO wouldn't pay for it. The doctor's office called the HMO and screamed at them, and lo and behold, we got what we needed.

 

[Cirrus]

I hate HMOs myself. My opinion is that they're just billing agencies. I had no choice but to sign up for this one, the other insurance we had available through work left the program because they weren't making a profit.

I'll try that Pokerman...hadn't thought of that. The only thing is, the insurance company's appeals dept has already thrown the claim out so I don't know how far I'll get.

 

[miles]

Insurance companies know one word: No.

The majority of people give up when the insurance company refuses a claim.

Document everything. You're pissed off, but be professional with everyone you talk with. Tell them you have a problem and need their help resolving it. Contact the Benefits person if your insurance is through an employer, and they should contact the HMO rep. That's their job. If the benefits person won't help you, escalate the issue higher up the food chain. Above all, be polite and firm, and don't talk with clerks. Go directly to the top.

 

[*Lazer*]

You should get that administrator to write a letter to your HMO and follow it with a explanation of what you did and how the nurse triaged you into the acute care side. Also call your congressman or better yet email him/her. It is only by people kicking up a fuss that we will start to regain some control over our health care dollars. The HMO's are like Bell Telephone before the break up. "We don't care because we don't have too."

You can also ask to speak to the arbitrator in the organization or appeal the decision. Include the fact that you have no intention of dropping this matter.

 

[rambling man]

I have been screwed over twice by insurance companies, well, my wife actually. She was injured and was eligible for compensation...she was out of work for four months and did not get a cent, even though we continued paying into the fucking plan. She quit after the second rejection although it still pisses me off.

A couple of years ago she was pregnant and had serious complications and she had to go off work. The plan where they pay your car payment if you have to go off of work for awhile said no, too. What good are these people?