Urgent Care Woes

[jeromedawg]

Hey all,

So about a month ago while on vacation in Hawaii, we took my FIL to Urgent Care late at night because he had a pretty bad cough, his chest hurt and his heart was racing. He initially waived it off as he thought he just had a bad cold but the symptoms weren't getting much better by the end of the week so we decided it would be best for him to see a doctor. We brought him to the closest Urgent Care facility in Waikiki (Doctor's of Waikiki) that was still open (near midnight) and had good reviews all around (including the doc).

My in-laws have Medicare and so my wife called the Urgent Care facility ahead of time to ask if they would take it. The person who answered initially told her "yes we take Medicare" so we decided to go. My wife had to go to help translate because he would have had a hard time with all that. At the front desk she was told by a different person that they only accept Medicare PPO and not HMO (my in-laws have HMO but my wife didn't realize there would be differences in coverages when it comes down to urgent or emergency services) - she was not told this over the phone. However, she was also told that they would take the Medicare card as-is and 'process' it and that the charges would still be 'adjusted' based on the level of Medicare (where some would be covered and others would be billed to my in-laws directly). He paid a $70-80 copay and the person at the front said she thought the bill might be a few hundred or so after these 'adjustments.' Since he was in pretty bad shape and since we were there and worried, we just decided to have him seen by the doctor. They checked for flu, put him on a nebulizer, and prescribed him some meds. He was fine after the visit and getting meds.

Just a couple weeks ago, they received a bill for $1100 in the mail. The bill has insurance completely waived from it due to them not covering the Medicare he has as well as this facility being out of network. Since this was late night, we didn't really have much of a choice - I suppose we could have brought him to an ER too but not sure how much that would have cost either.

Anyway, the whole thing with my wife asking if they accept Medicare and the answers they gave seems pretty misleading. The people answering the phone/at the front desk could have just been misinformed but for such a small practice/facility, you'd think they'd know all the details and be transparent about it up-front. Almost feels "bait and switch"'ish...

My wife called my in-law's Medicare insurance and they tried contacting the facility but were repeatedly told that no claim would be opened and the insurance also informed my wife that they couldn't force this facility to open one since they're out of network. The Urgent Care facility also claimed and told insurance that a prior authorization from PCP was required else they wouldn't submit a claim to insurance. Insurance says if that were really an issue, they could have retro'd it but the Urgent Care *never* informed us about this whole "prior authorization" thing.
Insurance did file a grievance on behalf of my in-laws but not sure where or how far that will go.
My in-laws recently retired (and not with much) so $1100 is a not a small amount for them.
Any suggestions on other things we can try or if there's any potential recourse in a situation like this? At least to reduce their bill? My wife has yet to call the Urgent Care facility directly so will probably be doing that, but we don't have a good feeling about it and think they probably won't budge much if anything on reducing the bill amount.

[socaso]

You could try to find a non profit health care advocate who works with Medicare. They might be able to leverage a lower payment.

In the future if you are travelling with your in laws it might be worth it to identify ER and Urgent Care facilities that will definitely take the insurance they have. However, my understanding of HMO's is that the providers are usually local and the insurance doesn't work out of state. That is the case for the HMO I have which is not Medicare. If that is the case for theirs then you might purchase travel insurance, which should cover them in case of emergency care.

[jeromedawg]

You could try to find a non profit health care advocate who works with Medicare. They might be able to leverage a lower payment.

In the future if you are travelling with your in laws it might be worth it to identify ER and Urgent Care facilities that will definitely take the insurance they have. However, my understanding of HMO's is that the providers are usually local and the insurance doesn't work out of state. That is the case for the HMO I have which is not Medicare. If that is the case for theirs then you might purchase travel insurance, which should cover them in case of emergency care.

Thanks - good pointers. Where do you start looking for a non-proift health care advocate that works with Medicare anyway? Seems like a very specific thing haha.

[MayDay]

I don't know a ton about Medicare, but I do know there are a ton of different plans. My idiot grandfather ignored my mother's (a health care professional) advice and switched to a cheaper plan which doesn't cover out of state. Like you, he called and asked if his FL doctor took it (he winters in FL), they said yes, and he switched. Well the FL doctor takes some plans but not his out of state one. So he spends 5 months a year in a state with no insurance, more or less.

Sounds frustrating, but typical. I wouldn't waste mental energy on it, you aren't going to win. They told you it wasn't fully covered when you got there. Someone over the phone couldn't possibly give you the details without seeing his card.

[DaMa]

I would file a complaint with the Hawaii Dept of Insurance:  http://cca.hawaii.gov/ins/consumers/filing_a_complaint/.  Then tell the provider you filed a complaint and offer to pay them $200 to settle the bill (what you expected to pay).

I would also write a letter to your Congressperson.  This is exactly the kind of problem that has been getting some attention lately.

[slappy]

Why wouldn't you just pay the $1100? Next time you can be more prepared, I guess. As with anything, it is no one's responsibility to know what your plan covers. It sucks, but I guess it could have been a lot worse, and in the the context of potentially life saving care, $1100 doesn't seem that bad.

Are you saying that Medicare didn't cover any of it? Maybe call and ask for a cash discount, or settlement as another poster mentioned?

[Cranky]

Okay, so your in-laws have a Medicare Advantage plan rather than “traditional Medicare”? Those are the terms you needed to use. Medicare Advantage plans are pretty clear that they have limited networks and don’t cover much when you travel. There should be a number to call BEFORE you go to emergency when you are out of network though, and they can advise you about coverage.

Since they didn’t follow the procedure, at least as I understand it, I’d say they owe the $1100.

[jeromedawg]

Okay, so your in-laws have a Medicare Advantage plan rather than “traditional Medicare”? Those are the terms you needed to use. Medicare Advantage plans are pretty clear that they have limited networks and don’t cover much when you travel. There should be a number to call BEFORE you go to emergency when you are out of network though, and they can advise you about coverage.

Since they didn’t follow the procedure, at least as I understand it, I’d say they owe the $1100.

So my wife checked and it's Medicare Complete, which I guess is a variant of Advantage. Unfortunately, we just weren't thinking about 'procedure' late at night when my FIL was feeling weird and my wife was freaking out. Especially when it was my wife acting on behalf of her parents, and not knowing the ins and outs of Medicare and all the differences. But now we know to double-check...

[jeromedawg]

Why wouldn't you just pay the $1100? Next time you can be more prepared, I guess. As with anything, it is no one's responsibility to know what your plan covers. It sucks, but I guess it could have been a lot worse, and in the the context of potentially life saving care, $1100 doesn't seem that bad.

Are you saying that Medicare didn't cover any of it? Maybe call and ask for a cash discount, or settlement as another poster mentioned?

So we were *told* by the Urgent Care facility that they'd submit a claim and whatever 'portions' were covered by Medicare would be deducted from the bill, etc. None of that happened. I don't now if that's an issue of 'coverage' or if it's an issue of the urgent care facility refusing to submit the claim. At this point it sounds like they're refusing to submit the claim due to lack of a "pre/prior authorization" from my FIL's PCP... does that sound right?

[slappy]

Why wouldn't you just pay the $1100? Next time you can be more prepared, I guess. As with anything, it is no one's responsibility to know what your plan covers. It sucks, but I guess it could have been a lot worse, and in the the context of potentially life saving care, $1100 doesn't seem that bad.

Are you saying that Medicare didn't cover any of it? Maybe call and ask for a cash discount, or settlement as another poster mentioned?

So we were *told* by the Urgent Care facility that they'd submit a claim and whatever 'portions' were covered by Medicare would be deducted from the bill, etc. None of that happened. I don't now if that's an issue of 'coverage' or if it's an issue of the urgent care facility refusing to submit the claim. At this point it sounds like they're refusing to submit the claim due to lack of a "pre/prior authorization" from my FIL's PCP... does that sound right?

Maybe...I know the pre auth can be important, usually from the insurance company, not the PCP. I would ask them to submit a claim. If they say something like "it won't get paid" just say "please humor me and submit it". Then you can check with with the insurance and see what they say.  You could even find out from the insurance company exactly how it needs to be handled and then give that info to the medical office.

I've had a similar issue and it took several back and forth phone calls to get it fixed, which seems normal these days when it comes to medical billing.

[DaMa]

Most Medicare Advantage plans have networks, and HMO ones are usually small.  With the info you've given, you are definitely out-of-network and on the hook for the claims if it was NOT an emergent or urgent medical claim.  Emergency or urgent care is covered in the US.  Your insurer needs the claim to determine if it is urgent.  The fact that the provider won't file the claim is at the heart of the problem and what you should complain about. 

Here is a good summary of info on Medicare Advantage plans:  https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

[JoJo]

Long shot but does he have a credit card that has some trip medical coverage?  My CSR has $2500 medical coverage for trips under 60 days. 

https://www.chase.com/card-benefits/benefit-details/JPM_Reserve/sapphire-emergency-medical-dental

[Peony2019]

In the State in which I live, out of network rules do not apply to Urgent Care and Emergency department services.  I recommend you ask for an itemized statement of services provided along w/ copies of the physicians notes and diagnosis and submit those to the insurance company in hopes that they will pay at least a Medicare rate.  Frame it that as a prudent consumer of healthcare your FIL was trying to keep costs down for both himself and the insurance company.  You could also check to see if there was an in network facility around and if not make the argument to the insurance company that one wasn't available even if you had known to go.  The Urgent Care company may not have to accept  insurance payment as payment in full but it would be nice for your FIL to get a portion of the bill covered. 

[SavinMaven]

The people answering the phone/at the front desk could have just been misinformed but for such a small practice/facility, you'd think they'd know all the details and be transparent about it up-front.

You'd think so.... but they don't. Medical billing and coding is a separate job from general clerical work, and they're almost never on-site. It's incredibly complex, and I'm sure the receptionist thought they gave you the right information, but this really isn't part of their job to know. Medical cost transparency is a big topic these days, and hopefully fixes are on the way, but until then it is often impossible to get a straight answer on cost before receiving care, especially if it's not an elective test or procedure you can shop around.

You can try your state's Medicare ombudsman: https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home.html

And in the future it can be wise to purchase travel insurance with medical cost coverage. Good luck!

[rothwem]

...but this really isn't part of their job to know...

It absolutely IS their job to know.  If they didn't know, they shouldn't have guessed, they should have found out the info, and the information should have been available. 

If it were me, I just wouldn't pay the bill, and I'd probably verbally abuse the urgent care people until the people cried on the phone and lowered the bill amount to something I consider more reasonable.  Not everyone is me though, and if they don't want the trouble they probably should just pay the bill. 

[DaMa]

Out of network rules do not apply to Urgent Care and Emergency department services for emergent and urgent medical care for all members covered by any Medicare Advantage plan.  This applies to all states.

Provider staff and billing people do not know what your insurance covers and what it doesn't.  Keep in mind these are mostly minimum wage jobs for people who can't do basic math.  I spend a lot of time reviewing medical bills and insurance statements for family and friends.  Providers make mistakes ALL THE TIME.

[AliEli]

I wanted to say that I am so sorry that you had to negotiate money before you could attend to your FIL's health. It's terrible that you should even have to ask those questions, especially at a stressful time with a sick family member. I hope he is feeling better and I'm sorry to hear about your huge bill.

[Freedom2016]

I'm not understanding pre-authorization in the context of Urgent Care.

You don't need pre-authorization to show up in an Emergency Room... why would you need it for an Urgent Care visit? I've never once needed it.

 

[LaineyAZ]

Sometimes it's as simple as calling the 24/7 Nurse Hotline.  You describe the symptoms and if they agree it's urgent they will tell you.  Then you can go knowing it's covered.
But I agree - you'd think that as a sane adult that you would be able to make that decision for yourself and not have to go through a gatekeeping step which is used to prevent people from over-using the very expensive emergency system.

[Cranky]

The *reason* Medicare Advantage plans are less expensive and have fewer deductibles is that they have a limited network. They fully disclose this, and make it clear that they are not suitable if you travel a lot.

[jeromedawg]

Out of network rules do not apply to Urgent Care and Emergency department services for emergent and urgent medical care for all members covered by any Medicare Advantage plan.  This applies to all states.

Provider staff and billing people do not know what your insurance covers and what it doesn't.  Keep in mind these are mostly minimum wage jobs for people who can't do basic math.  I spend a lot of time reviewing medical bills and insurance statements for family and friends.  Providers make mistakes ALL THE TIME.

I stumbled across this (although there are other sites that seem to indicate otherwise, in that Medicare Advantage coverage at Urgent Care Facilities is "YMMV"):
https://www.medicareadvantage.com/common-questions/does-medicare-cover-urgent-care

"Does Medicare Advantage cover urgent care?
By law, every Medicare Advantage plan must cover the same benefits that are offered by Original Medicare, which means Medicare Advantage plans will cover urgent care. One exception is hospice care, but you still receive coverage under Medicare Part A even if you are enrolled in a Medicare Advantage plan.

Some Medicare Advantage plans may require you to stay within a specific network of providers, though exceptions can often be made when you need emergency medical care and cannot get to a facility that is within your plan’s network."

I guess the first thing is that we need to determine if my FIL's *specific* Medicare Advantage plan (I didn't know there would be differences and variations even within this sub-plan) has the requirements to stay within the specific network of providers. But when they say "exceptions can often be made" I don't know what that's based on

However, I ended up looking up the doctor who treated my FIL and he *is* listed on the Medicare.gov site - the address listed is the same address/location. It even has the Urgent Care group name that he's affiliated with listed.
In both cases, there's a row under the "General Information" for this doctor with a green check mark next to it:
"Medicare-approved payment - Accepts Medicare-approved payment amounts"