Anthem denied every part of my emergency surgery.

[u/shibesanon]

EDIT: I am getting this taken care of. THANK YOU TO EVERYONE WHO GAVE ADVICE

August 20th/21st I had to have emergency surgery on my lower intestines. Removing 6 inches and being stuck in the hospital for 5 days. The surgery caused my intestines to stop working for two days. I was supposed to stay in longer/not go to work. But I ended up leaving on the 25th and returning to work the 1st. And yesterday I got billed over 123k. With anthem refusing to pay a single dime.

I don’t even know where to go from here. I’m just lost.

I make less than 35k a year… how the fuck am I supposed to pay that?

[u/One_Struggle_]

I'm going to preface this by saying I work as a nurse whose primary job is yelling at insurance companies so the non-profit hospital I work at gets paid.

First, the hospital you went to, was it in network? Second at any point did you sign anything stating you were responsible for the bill if insurance refuses to pay? Third, are you in the US? Lastly, is this insurance though your employer or some sketchy policy off the market place?

Generally speaking what happens when a patient is admitted, the hospital needs to notify your insurance that you are admitted & send doctors notes & other clinical information to prove the medical necessity of your admission within one business day.

If the hospital fails to do that or the insurance company misplaced the faxed information or the information sent didn't have the full picture (cause remember it's only the first 24 hours & half the time the doctors notes aren't even finalized yet), the insurance will deny the stay citing various denial types (no notification, no clinical, not medically necessary, etc)

If in network, this dispute is solely between the hospital & your insurance company as per contract, you can only be billed for your regular copay only. Basically the hospital will have a few options to appeal the denial at this point.

I have many times received calls from patients freaking out because they received a denial letter & let them know it's going to be fine, we already appealed it, sometimes it's already approved in the time it takes the mail to get to your home.

For out of network, the no surprise act would kick in for most issues in the US

https://www.consumerfinance.gov/ask-cfpb/what-is-a-surprise-medical-bill-and-what-should-i-know-about-the-no-surprises-act-en-2123/

I'd advise you call the hospital & ask to be transferred to the Utilization or Case Management department. That staff is generally a Mon-Fri from 8-4pm as that is when insurance is open. You want to speak with whomever does the notification for the hospital. Ask if they are aware of the denial, if it's been appealed & if a decision was made yet (ie denial overturned or upheld). If still denied, you as a member have the right to appeal the decision with your insurance. I can tell you now that the procedure you had is considered an inpatient only surgery & absolutely meets medical necessity criteria. There is probably something in the denial letter mentioning InterQual or MCG guidelines for denial. A hemicolectomy is medically necessary as an inpatient admission under both.

So unless you went to an out of network hospital, signed a form stating you are responsible for bill (notice of non-coverage), not in the US and/or bought some garage policy off the market place that has no inpatient hospital coverage, I'm fairly certain the hospital is already in the process of getting this resolved, because that is a big bill & they very much want your insurance to pay it.

[u/Tcherryrn → u/One_Struggle_]

Perfect explanation and direction, I second every step advised.

[u/shibesanon → u/One_Struggle_]

It was in network. I specifically went to one within my network. Because my mom at first believed it was just food poisoning or appendix (after I had gone to an in-network urgent care and they found a giant mass where my intestines had twisted and perforated. If it helps I was diagnosed with Meckel’s diverticulum)

I was mostly unconscious for three of the five days I was in the hospital and my parents never signed anything on my behalf. Besides hunting down nurses when I wasn't attended to in over 12 hours and the only person to come in was bringing food that I couldn't stomach without projectile vomiting. And that's when they learned that my bowels were inactive and they put a tube down my throat without ppe or telling me what was happening)

I never met any of my doctors, and if I did it was while unconscious.

It wouldn't surprise me if this is the hospitals doing. It was a learning hospital (OSU) and I admittedly had a terrible time there. I was so happy when my period started and I basically shit myself. And they went- yep, that works. Goodbye.

It also wouldn't surprise me if my insurance just hates me.

I will call billing again and ask about case management. Thank you.

[u/One_Struggle_ → u/shibesanon]

Don't call billing (it's usually outsourced), call the hospital main number, ask operator to transfer you to Case Management or Utilization Management or whoever doesn't authorizations there. Again, I'm willing to bet it's already been taken care of.

[u/Silent_Dinosaur → u/shibesanon]

A perforated Meckel’s diverticulum is a surgical emergency and an ex-lap w/ SBR is definitely medically necessary. Without surgery that would likely be fatal. Postop ileus after peritonitis is not surprising, in fact I’d say it’s almost expected.

Point being your insurance should definitely cover this.

You definitely met your doctors, though, whether you remember it or not. At least one doctor or ACP from the primary team has to see you each day. I can’t tell you how many patients have claimed “I never met a doctor” because they don’t realize that women and minorities (and young-appearing people) can be doctors too.

Chances are the person who placed your NGT was a resident, which is a junior doctor. They definitely should have told you what they were doing and why when they placed the NGT, as that’s a very unpleasant—but necessary—experience. The only PPE generally used for that is gloves, as the GI tract is not sterile, and is mainly just to protect them from your snot. Sorry they didn’t have good bedside manner. The residents are usually overworked (80-90 hours a week) and underpaid (less than the nurses) which is an explanation but not an excuse. I like to think I was always kind despite those pressures, but it’s not easy.

The hospital and insurance, though, definitely don’t hate you. They are just large impersonal entities. There are, however, people at these places who do actually care, you just have to find the right people.

Not medical advice, but I’d suggest contacting the hospital’s patient advocate, case management, social work, or utilization management. Someone there should be able to help you. Also if all else fails, figure out who your attending doctors were and ask their offices for help. That surgeon is probably getting paid like $500 dollars for saving your life, they definitely don’t want you stuck in debt for it.

Anyways, good luck with this. I’m sure if you’re patient and talk to the right people, this can be resolved

[u/shibesanon → u/Silent_Dinosaur]

The hospital acted like my post-op ileus (sorry I didn't use that word earlier I didn't know what it looked like I'd only heard it) was some anomaly.

I do vaguely remember waking up at 5am and vomitting on a woman who looked straight out of Grey’s Anatomy. And then crying. I was HEAVILY drugged for the first three days.

My mom said that after my surgery I wasn't attended to for twelve hours and she and my dad had to hunt down nurses who they'd find congregating in random halls.

When the three girls put the tube down my nose they tore a large chunk out of my nostril and I bled and exorcist level projectile vomiting on all three, while incoherenting sobbing. I had also been admitted into the hospital and left In a hall from 3pm - 12am. Then was in ‘exploritory surgery’ with six residents till 6am.

Overall I hated my experience there but I will try to do what you suggested. Thank you.

[u/Silent_Dinosaur → u/shibesanon]

Not sure why they acted like it was unusual; rate of ileus after abdominal surgery is 10-20% and much higher in emergency or contaminated cases like you’re describing.

https://www.sciencedirect.com/topics/medicine-and-dentistry/postoperative-ileus#:~:text=Postoperative%20paralytic%20ileus,23%2C25%2C26%5D.

The Gray’s Anatomy woman was likely someone from the surgical team. Maybe your surgeon. They usually round very early in the morning because they have to see everyone before surgeries start which is usually ~ 7:30 AM

Heavily drugged shouldn’t be the norm anymore, unless you were in the ICU/intubated. But even regular medication doses can compound with sepsis and/or anesthesia and/or physiologic stress to cause delirium and/or memory issues. Impossible to tell without looking at your medical record, but just explaining that medications aren’t the only reason you might have a foggy memory.

The nurses shouldn’t leave you alone for 12 hours; that’s usually the length of their shifts. I think most hospitals have a vital signs frequency of every 4-8 hours, unless they’re horribly understaffed. If truly nobody came in your room for more than 12 hours at a time, I’d say that’s worth complaining about.

Nosebleeds can happen during NGT insertion, and the exorcist vomiting shows you definitely needed an NGT.

I hate the ER hallway. That happens at overcrowded centers unfortunately

Six residents doesn’t sound right. Every surgery has to have an attending physician there. Learning centers often have 1-2 residents and maybe a student as well. Very rare that a surgery would have 6 residents involved, even if the surgery was unusual and spanned over shift change, I think 4 would be the max. Not saying that’s not what happened to you, just unusual.

If you had a bad experience, it’s worth letting the hospital know. Might just be yelling into the void, but most doctors go into medicine to actually help people. Nobody is going to the hospital with perforated bowel and going to have a great time, but doesn’t have to be truly miserable.

Good luck 🍀

[u/sqrrrlgrrl → u/shibesanon]

You need your EOB first. Why did they deny your claim? Then you can call billing and figure it out. I'm with the above nurse as I saw it so many times at the appeal level. Then you can call billing, who can get it straightened out with you and resubmitted.

If for some godforsaken reason they don't pay it as inpatient they should still cover anything that would have been paid as outpatient. It will probably be a process, but you should never be liable for the whole inpatient bill for a PPO hospital.