Our In-Network Hospital Moved a Patient to an Out-of-Network Hospital for Emergency Surgery, What Do I Do?


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Medical insurance and stays at a hospital may become complicated when the patient is moved from one location to another. However, if the initial hospital changes from an in-network facility to an out-of-network place, this may affect insurance coverage rates and how much is owed on the final bill by the individual.

This may require additional research and contacting the insurance carrier for clarification. Typically, the stay would only incur a deductible for the first place while the rest of the treatment is taken care of either at an outpatient facility or at home. In these situations it is important to contact a lawyer versed in medical insurance and medicine.

When a bill has been given to a patient that had no choice in what hospital was used, it may not be the responsibility of that person to pay the larger deductible or rate as he or she was given no choice in the matter. This is often due to the individual being either unconscious or in a manner that leaves him or her unable to communicate. There are often very specific stipulations in the fine print of insurance policies that cover these matters, but Legal assistance may be necessary to resolve the issue so that the bills may be paid correctly.

Policy Stipulations

Many healthcare policies have specific fine print and extensive documentation about what is considered in and out of network for the location the patient lives in and where he or she may seek medical care. The pricing differences of going to one hospital or doctor over the other is usually a percentage such as a different of in-network being paid up to 90 percent while out-of-network may only pay 20 percent of healthcare costs for treatment, surgery and stays in the facility. While this does not usually extend to medicine, the difference in payments is often enormous especially when there is generally a hefty deductible to start out with that must be paid before the rest kicks in for the person.

This problem where someone has been moved to an out-of-network hospital affects more than two million individuals that must go to the emergency room. These persons wake up after being treated to find they owe a much larger bill than is necessary due to additional charges that their insurance policy does not cover or only pays a small percentage of for the visit. In certain situations, the insurance plan agreed to cover the bill, but usually the fees must be paid by the patient. An expert or lawyer may need to be contacted or these events to assist the victim of these circumstances.

Unexpected Expenses

Bills are often much higher than usual when being moved to out-of-network facilities. Even though a patient may start at the in-network hospital, at least a portion of the final bill will reflect the other location. The out-of-network hospital may even be in the same parking lot as the in-network location, but due to the insurance policy, the fees are not covered at least to an extent. The expectation is that when going to an in-network place, the person will be treated by someone that is covered in this aspect. However, hospitals may not ensure this when treating the individual, and the in-network portion of the insurance policy may not be honored.

It is possible that some facilities move a patient purposely to incur a greater medical bill. With the advent of special medical insurance coverage, some persons are covered through the Affordable Care Act and the fees may not be paid to the facility directly or immediately. This could lead to hospital personnel attempting to bypass this and take the individual to a location that is not covered by policies. The same is possible when insurance is paid for by the patient but is covered through an in-network coverage that ensures up to 90 percent goes through the insurance agency.

Legal Recourse for Hospital Stays

It is imperative that the insurance agency is contacted for the hospital stay. The facility used to treat the person should be contacted immediately as well to understand why the individual was transferred to an out-of-network location when the insurance policy specifies what is covered when the staff call from the forms filled out. A lawyer that understands insurance and medical care is necessary to protect the patient from needing to pay amounts that are not possible due to financial complications.

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Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.

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