Surprise $6k bill for appendectomy I had a year ago

I am royally confused and would really appreciate any advice/help from someone with more knowledge than me. I have a Blue Shield Gold 80 PPO with Blue Shield of CA.

Went to ER with appendicitis, admitted to hospital for an emergency appendectomy. Received a bill 11 months later for $6k+. I thought the claim had been finalized but it was adjusted a few times in the last year.

Filed a grievance with Blue Shield of California and they sent a letter back saying that I am responsible for 30% of the allowable amount of inpatient hospital services. My summary of benefits says that if I’m admitted to the hospital in an emergency situation that I pay the participating provider payment under inpatient hospital services. In my EOC, it says “The Emergency Benefit also includes Hospital admission when inpatient treatment of your Emergency Medical Condition is Medically Necessary.”

Later in the grievance resolution later it says “if you believe that this decision was medically necessary, you may contact the Department of Managed Healthcare at…”

It seems there is a discrepancy between the EOC and Summary of Benefits, or at least it’s a bit vague. I’m mostly curious about the term “medically necessary” and if that precludes me from having to pay 30%? It’s not like anyone came and said “hey you’re gonna pay 6k… would you rather shop around and see if you can get this surgery cheaper somewhere else?” instead it was “we’re admitting you to the hospital for surgery right away”

So far no one at Blue Shield has been able to explain this to me. Does anyone have any advice or clarification to help me better understand my responsibilities?

submitted by /u/kadotafig
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