Surprise bill situation out of control
Sorry for the novel, this has been developing for over a year.
I am insured on a student health plan through a university in New York. In November 2021 I had a kidney stone and went to an in-network hospital’s emergency room in New Jersey. A urologist came in, ran some tests, and determined that the stone would have to be removed. They kept me overnight and performed the removal the following morning. A stent was placed at this time. A week later, I had a follow-up appointment at the urologist’s practice (also in NJ) where the stent was removed.
Cut to February 2022, I get a bill, making me aware that this urologist was in fact out-of-network. Evidently they had me sign a form acknowledging this fact at the follow-up appointment, but I don’t remember that, I was in the waiting room anticipating having the stent pulled out after a week of painkillers and having a foreign object in my body, and I probably would have signed anything at that point. I really don’t see what choice I had at the moment anyway, the stent was already in there.
I try to initiate an appeal through the insurance company, it goes nowhere. They advise me to submit a “surprise bill” appeal. I do that in March 2022 through their online submission tool. I periodically call to check on the status of this appeal over the next few months and they keep telling me it’s in process. In October 2022 I find out they actually never received my submission and, as far as I can tell, confused a separate appeal for the one I was asking about. They advise me to write a detailed appeal letter with all of this information, which I do. Predictably, they reject the appeal, stating that they must bill me according to the status of the doctor as out-of-network.
After a ridiculous amount of back and forth I manage to get a three way call going between me, a rep from the insurance company, and someone from the urologist’s billing department. They debate for a while and use a lot of medical billing jargon about codes and qualifiers that I don’t understand. The gist of it is that since the follow-up appointment took place at a separate facility from the hospital it doesn’t matter that they were removing a stent placed during the initial surgery, it doesn’t fall under the same rules as the initial surgery (which I also had to appeal the bill for, and has been handled, again through a process I am unable as a layperson to understand). There seems to be some confusion about the fact that the follow-up was solely to remove the stent and I didn’t have any choice in the matter. Nobody in their right mind would seek out another doctor to remove a stent, even if they were aware that the original doctor was not in-network.
The insurance rep and billing person both advise me to contact a “community health advocate” to assist in navigating the process of an external appeal, because apparently it’s my responsibility to sort this all out. So I contact the advocate and they kind of seem like they’re trying to help but they’re also dragging their feet a lot and I can’t help but wonder if they’re really part of the grift and are just frustrating my attempt at a fair external review. They’re telling me that since the New York surprise bill laws were not in place at the time of the surgery and stent removal, basically the insurance company doesn’t have to cooperate.
Where we are now… the advocate is going to send a grievance letter to the insurance company asking for a one-time exception so this can be covered. They seem to think that this isn’t going to work. The turnaround time they gave me for this is 30 days, which will take me beyond the 4 month period where I could file a request for an external appeal, as I understand it (and I don’t really understand how to get the external appeal anyway). This whole process has been a nightmare, I’ve done everything the insurance company told me to do every step of the way. Nobody will give me a straight answer about anything. I don’t even understand why an out-of-network doctor is in an in-network emergency room in the first place.
If there’s something I can do to figure this all out, I would very much appreciate the information.
