Struggling with In vs Out of Network Claim

Billing question about in vs out of network and maximum deductibles.

Wisconsin, USA

All hospitals, ambulance companies, and my house are within 12.5 miles of my residence and each other.

Billing as of 29Sep2023

• Hospital #1 – Initially billed In Network (resolved)

• Hospital #2 – Initially billed Out of Network (unresolved)

(Attempt 1 – Amount Billed $19,070, Plan Paid $6,309, Total Owed $12,761)

(Attempt 2 – Amount Billed $12,761, Plan Paid $4,946, Total Owed $7,815)

• Ambulance Ride #1 – Initially billed Out of Network (resolved)

• Ambulance Ride #2 – Initially billed Out of Network (resolved)

Hospital Stay

My second son was born in August 2022. At 10 weeks old, he was transported ~20 minutes via ambulance to our in-network hospital due to RSV. My wife had left to take him to Hospital #1 (in network), but he began aspirating on vomit, so she pulled over and called an ambulance.

Hospital #1 was full of kids with RSV that evening, and my son was treated in the hallway overnight. There were no beds available, and it was not known when he could be properly admitted. That morning, the team advised that he be transported to Hospital #2 (out of network) for treatment as Hospital #2 had a room for him in the NICU. I’m sure this isn’t binding in any way, but we were assured by the team his stay at Hospital #2 would be treated as in network for insurance purposes due to the lack of beds at Hospital #1. He received treatment and was released after a little under a week.

Health Insurance

I have a high deductible plan, with a maximum in-network out of pocket expense of $5,000. This was obviously met in 2022 due to the birth of my son. I also have an out-of-network, out of pocket maximum of $6,000. It is unclear to me if these overlap (I’m nearly certain they do), but I believe the out of network limit is for combined in-network and out-of-network costs.

Billing…

Both ambulance rides were initially billed as out-of-network. It is mind boggling to me that an ambulance ride, essentially from my house to my in-network hospital, was billed as out of network. The second ambulance ride, from Hospital #1 to Hospital #2, was also billed as out-of-network. These hospitals are 2.4 miles apart – a 10-minute drive.

First ambulance claim was paid before we realized the extent of the billing fiasco. This was ultimately reprocessed by the insurance company as in-network and the cost reimbursed. We disputed the second out-of-network ambulance claim, though it did go to collections for a brief period. I ended up “winning” the dispute as clearly the ride occurred in network. Claim was reprocessed as in-network, paid by insurance, and removed from collections.

In-network Hospital #1 submitted several bills/claims. All were treated as in-network and paid by insurance.

The “out-of-network” Hospital #2 claim was billed at $19,070 on 11/17/2022. My insurance partially denied this claim, leaving me with a total amount owed of $12,700. I disputed this denial for two reasons:

• Claim considered in-network due to circumstances.

• Amount Owed exceeded my maximum out of pocket expense.

As part of the dispute, I provided the insurance company with doctor’s notes and other information to show that Hospital #1 was full (not admitting new patients) and that I believed the stay should be considered in-network. The dispute resulted in a claim reprocessing, which was also partially denied on 3/3/2023 – Amount Billed $12,700, new total amount owed $7,800. I have no insight into the nature of these denials, nor what was updated to increase the coverage but not change network status.

As part of my insurance, a “plan advocate” is available to discuss and assist with issues. While attempting to resolve this, I have spoken with an advocate on numerous occasions. Initially had a hard time conveying the situation, but the advocates seem to agree that the billing should be in-network and the costs shouldn’t exceed my maximum out of pocket expenses. However, every time I speak to an advocate and think we’ve found resolution, nothing happens. There has been at least two occasions in which the claim was supposed to be reprocessed and hasn’t been. The most recent time I was told it will be billed as in-network after I contacted a third-party negotiator to attempt to reduce the claim amount. I went through this process, which concluded with Hospital #2 not negotiating. No movement on the insurance company’s part. This has also gone to deb collections and I’m afraid if I pay it will be much more difficult to get the money back.

I don’t know what “out of pocket maximum” means to my insurance company, but to me it means the most money I must pay out of my pocket, and I have absolutely met this deductible. Am I misinterpreting anything here? To say this has been stressful is an understatement. I’ve beaten my head against this wall and thought resolution was achieved several times. However, there has been no action from the insurance company that I can see. Planning on calling the advocate again but I’m not sure what other options I have. Advice would be tremendously appreciated.