r/HealthInsurance • u/videokillradiostarr • Feb 27 '25
Claims/Providers Had an emergency hip replacement. Hospital put me in a private room and insurance will not cover it. It's over 10k and I never requested it.
As the title says. I woke up from surgery and wheeled into a room without even knowing what was going on. I had emergency surgery to replace my hip from an accident. Insurance now says I owe over 10k becuase a private room was not necessary and they only cover semi private rooms.
What can I do here? I was expecting to only have to pay my max out of pocket rate. And now this is a huge upset.
Thanks in advance for any insight.
EDIT: I appreciate everyone's comments. I am going to call Hospital Billing to see what they can do. I will update when I find out the results.
For anyone looking at this in the future. I am in Texas. These are the codes that insurance used to deny the private room rate.
1 According to our guidelines, a private room was not medically necessary. Therefore, the payment is being made at the semi-private room allowance. J8530
2 The difference between the private and semi-private room charge is your responsibility. Private room is not a covered benefit for the reported diagnosis. Y5519
168
u/harryruby Feb 27 '25
If your insurance plan only covers semi private, and the hospital put you in a private for medical reasons, or because they don't have semi private rooms, there is a code the hospital needs to put in a field on the UB-04 claim form they file to the insurance.
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u/Berchanhimez PharmD - Pharmacist Feb 28 '25
This is the answer. If there is no semiprivate room available, the hospital codes it as such (i.e. telling the insurance there is no possible way to have given you a semiprivate room) and the insurance will pay for a private room.
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u/Masters_pet_411 Feb 28 '25
This. My son had an appendectomy and was put in a private room but the hospital told the insurance it was semi private, or that's what the EOB stated anyway.
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u/lEauFly4 Feb 28 '25
This is the case at the hospitals in my area. They don’t double up patients unless they have to, so you get a “private” room that is billed as semi-private (because technically they could put a roommate in there; they just don’t).
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u/Educational-Gap-3390 Feb 27 '25
Do people still share hospital rooms? Where I live that’s not a thing.
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u/indiana-floridian Feb 27 '25
North Carolina. Older hospitals built for semi private rooms aren't going to give up that extra income.
I would expect newer hospitals to be built as private rooms, if not I would seriously question why.
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u/LawfulnessRemote7121 Feb 27 '25
All the hospitals in my area converted their semi-private rooms to private years ago.
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u/HTravis09 Mar 02 '25
Private rooms are the new standard of care. New hospitals are not allowed to build semi private rooms.
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u/lysistrata3000 Feb 27 '25
Not true really. I work for a hospital chain, and every single semi-private room was converted to private years ago. They sent a notice letter to all insurance companies contracted with them that the beds were changing. If any claims were denied, they were straightened out swiftly.
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u/Foodie_love17 Mar 01 '25
My hospital (and the other closest one) absolutely uses doubles still. It would give up half their ability to do only privates. We rarely have available beds as it is, so there’s not a chance of converting to private anytime soon.
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u/jellifercuz Feb 28 '25
Shared rooms are still used at Penn State Hershey hospital (flagship teaching hospital) as well as many other hospitals in Central Pennsylvania, including that which serves the county in which I live.
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u/Berchanhimez PharmD - Pharmacist Feb 28 '25
Basically all hospitals outside the US are still semi-private at best. It's only a US thing that private rooms are the norm.
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u/One_Ad9555 Feb 28 '25
Wrong, I know all kinds of hospitals across country that have upgraded those rooms to private. If the hospital has enough rooms to do it they will. I spent 3 weeks in a hospital first build in 20 in 2015 and had a private room the whole time. Last time I didn't have a private room was back in 1991.
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u/mamallama2020 Mar 01 '25
The hospitals in my area were built in the early 1900s. Like, one was built in 1916 and the other was built in 1927. Set in the middle of the cities they’re in, there’s no physical room for expansion and the loss of inpatient beds from switching to private only rooms would seriously impact their ability to care for the community. Semi-private rooms are the norm around here.
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u/Nova-star561519 Feb 27 '25
My L&D post partum rooms were shared. We ended up getting one of the few private rooms but I was super small and we had to share the bathroom with the room next to us
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u/The_BoxBox Feb 27 '25
I would be so upset if I had to share a PP room, especially if the mom next to me was constantly getting lots of visitors. I have a feeling I won't want to be seen so soon after giving birth.
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u/Nova-star561519 Feb 27 '25
Yea I thank God I didn't get a shared room but it was SO awkward sharing a bathroom. The door locked from either side when someone was in there but it just felt so weird (and ngl kinda gross with all the post partum discharge and stuff)
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u/ThisCatIsCrazy Feb 27 '25
God that’s horrible. Immediate Postpartum recovery involves a lot of bleeding on the toilet seat.
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u/Nova-star561519 Feb 27 '25
Yup, and then they just had a basic little trash bin (no cover) to dump your bloody diapers and pads 🤢😩
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u/One_Ad9555 Feb 28 '25
Wow, most hospitals have gone all in in mice big private rooms for l&d
Was it in a big city?
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u/Nova-star561519 Feb 28 '25
It was a fairly big city in south east Florida. Very large hospital. The labor room itself was big and private. It's just the post partum rooms are crap. Which kinda sucks because you go from this big beautiful private labor room to this teeny tiny crap room. The nurses both L&D and post partum were so lovely but the post partum rooms was crazy for the size of the hospital (also very wealthy donors for the hospital. One of them owns/funds a college in the same town)
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u/One_Ad9555 Feb 28 '25
That's why it was semi private. Big city hospitals generally are older and in areas they can't expand without building a brand new hospital complex in another location. They don't have enough rooms so they still use semi private to maintain the number of rooms they need.
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u/Nova-star561519 Feb 28 '25
Ah interesting. Funny enough while I was there they were building a huge new section (just not an addition to the Maternity ward lol)
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u/One_Ad9555 Feb 28 '25
As for building, all depends if there is room to build. Hospitals are expanding so they can compete. Patients want private rooms and the latest and greatest.
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u/Shortstack997 Feb 27 '25
Oh yes all the time. You must live in a small town, most hospital rooms in big cities are semi private so they can squeeze as many custo... patients in as they want.
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u/One_Ad9555 Feb 28 '25
In small towns they have all gone private. They generally have 25 or less rooms. Not sure if it's still 25 rooms. So they get class8fied as critical access hospital to get max medicare reimbursement
1
Mar 02 '25
Not all of them. My dad just got surgery in a tiny town and he was in a shared room.
I felt bad for the dude next door because his family visited one time for like maybe 2 hours. The only time we were gone was while my father was asleep.
1
u/lysistrata3000 Feb 27 '25
Not true in my city. All three hospital entities in my city are private rooms now, including the one I work for.
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u/rosewalker42 Feb 28 '25
I was just in the hospital after emergency surgery for a broken leg/ankle and got put into a shared semi-private room with no limit to visiting hours. After that experience I probably would’ve paid $10k for a private room even if it meant selling a kidney or two. Not even the dilaudid made it tolerable.
2
u/SadNectarine12 Feb 28 '25
My old hospital was private rooms but we could flex to semi private if needed. Happened once on my med surg floor during a particularly bad respiratory season. I work for the VA now and some of the floors have what I call “party rooms”- they can hold up to 6 patients at once, with Magic Curtains of Anonymity for HIPAA.
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u/itsamutiny Feb 27 '25
I'm in NY and the hospital where my FIL had quintuple bypass surgery has semi-private rooms. The other bed wasn't occupied while he was there, though.
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u/aikhibba Mar 01 '25
We board 3 patients in one room all the time. This is in coastal California, expensive area to live in. None of the hospitals have private rooms except for a few isolation rooms. Some of them even put 4 patients in one room.
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u/AdamDet86 Mar 02 '25
The hospital I work at all rooms have been private since they tore down and rebuilt 20 years ago or so.
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u/worhtyawa2323 Feb 27 '25
Where are you located? Semi private rooms don’t even exist in my local hospital system due to HIPAA violation concerns
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u/MissyChevious613 Feb 27 '25
My hospital no longer has them (rural Midwest). Not only is it a HIPAA issue, the curtains dividing the rooms are an infection control issue. The ER still has curtains but they're outside of the glass door, not inside.
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u/kumoni81 Feb 27 '25
Work in a Midwest hospital. We still have them. New buildings being built don’t have them but our older ones do. Even with the shared rooms we never have enough rooms for everyone that needs to be admitted.
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u/PotentialDig7527 Feb 27 '25
Same here. Because it continues to be challenging to discharge to facilities we find that we have to fill every bed we have available. Also hard to discharge to home because of delays in Home Care starts.
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u/One_Ad9555 Feb 28 '25
That's why you still have them. If you had enough rooms they wood have been converted to private
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u/videokillradiostarr Feb 28 '25
Texas. My whole floor was private rooms after surgery. When I was in the emergency room, I had a shared room. Also, I was parked in a hallway for about three hours. I shared with the whole damn department.
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u/worhtyawa2323 Feb 28 '25
I would think you could appeal this, especially if you post op for doesn’t have an option to be placed in a semi private room.
Maybe also be covered under no surprise billing since you did not choose to be sent to a private room as alternative options were not discussed beforehand and your situation was not expected
12
u/Ihaveaboot Feb 27 '25
Do you have an EOB letter from your plan yet?
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u/videokillradiostarr Feb 28 '25
Yes, this is where I found out my cost. Planning in calling hospital billing to see if we can sort it out.
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u/Rabbit-Ragout Feb 27 '25
I assume this hospital was in network and you are in the US? If yes, then most of the time the hospital is not contractually allowed to bill you for something that was non-covered unless they received written consent from you before they provided the non-covered service. If you receive a bill from the hospital, and you did not consent, call your insurance company.
If not in network, then you should be protected by the no surprises act since you were admitted after being in the ED.
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u/Magentacabinet Feb 27 '25
On the EOB there is an option for you to submit an appeal. You need to appeal the specific charges for that room. Stating that you had no choice of room that the hospital had placed you in after you woke up from emergency surgery. Let me know if you need help putting together the letter.
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u/oklutz Feb 27 '25
Insurance doesn’t have the final say. The billing provider does. The insurance just dictates the most the provider can bill you.
Did insurance deny the private room in full, or did they pay up to the semi-private rate and deny the rest? If they denied in full, the hospital may resubmit the claim and just charge for a semi-private room. If they paid the semi-private rate, a lot of the time the hospital will accept that and write off the balance.
Call the hospital billing department to know how much, if anything, you would be responsible for.
1
u/videokillradiostarr Feb 28 '25
Yes, they paid partial up to the semi private rate. I will see what hospital billing has to say. Thanks!
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u/uffdagal Feb 27 '25
The hospital, ideally, should not bill it as single room if it's the only available room. Call them first.
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u/CactusWithAKeyboard Feb 27 '25
Reach out to the hospital and request a letter explaining why you were placed in a private room instead of a semi private room. Then appeal with your insurance using that letter.
If there were only private rooms available, or if a private room was medically necessary, there are "condition codes" the hospital can include on the bill that can explain this. However, sometimes asking for a letter is easier than asking them to correct the coding.
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u/majortahn Feb 28 '25
Not sure if the policy of that hospital, but we don’t allow post op patients to share rooms. It’s an infection risk. Seems like the insurance should make an exception!
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u/One_Ad9555 Feb 28 '25
Most likely a billing issue. Call hospital billing department Most hospitals only have private rooms now days.
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u/KismaiAesthetics Feb 27 '25
If you didn’t request it, I’d say the hospital threw it at the wall to see if it stuck or the doctor ordered it. Either way, it’s on them to appeal at this point.
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u/ppppfbsc Feb 27 '25
why hospitals in 2025 still have anything but private rooms is beyond me. when you stay at the Hilton do you get a random roommate so why when you are sick or injured you have to share a room is bizarre if you think about it?
let the hospital and the insurance company figure it out. most new hospitals only have single rooms so what does your insurance company do with a more modern hospital? ask them.
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u/evan938 Feb 28 '25
I work for hospital billing. They should be able to let the payer know they don't have semi-private rooms and it'll get paid. Shouldn't be a big deal at all.
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u/Nesta_Archeron1 Feb 28 '25
Are you in the US? If I’m not mistaken, this is what the No Surprises Act exists for. I would definitely contact the hospital’s billing dept.
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u/dick-lava Mar 01 '25
i was put in a semi-private room for overnight cardiac observation…with an old guy who shat in a bedpan stinking up the place…was insulting and made racist remarks to the aides who came to the room…kept his lights and television on past 11pm…middle of the night started hollering for a nurse and when i told him to push his call button he started yelling at me…i told him to shut the fuck up or im getting out of bed to smack him…got to hollering and the nurses came and got me into a private room as we woke the whole ward…fucker!
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u/rrhunt28 Feb 27 '25
Not an expert but depending on the circumstances a private room may have been medically necessary.
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u/Ok-Helicopter3433 Feb 27 '25
What does the denial code say on your EOB? If a network facility, the patient should not owe.
There are codes that should be billed on facility claims that indicate that either no semi private room is available, or that private room was medically necessary. If not, they are supposed to provide the semi private room rate. In that case, the worst case scenario involves a denial of just the difference between the private room and semi private room rates. This is usually a few hundred dollars, from what I've seen.
I'm guessing that the insurance company may have pended or denied and asked for missing codes or semi private room rate, and are not denying the claim entirely.
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u/videokillradiostarr Feb 28 '25
They did pay the semi private rate. The difference is what is over 10k.
1 According to our guidelines, a private room was not medically necessary. Therefore, the payment is being made at the semi-private room allowance. J8530
2 The difference between the private and semi-private room charge is your responsibility. Private room is not a covered benefit for the reported diagnosis. Y5519
Going to call hospital billing to see if they will appeal or accept the semi private rate.
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u/Adventurous_Soft5549 Mar 03 '25
It's Texas - I've learned the hard way that Texas and most Texans don't give wo shits about people!!
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u/Midmodstar Feb 27 '25
What country are you in? In the US, shared rooms are very uncommon.
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u/aguafiestas Feb 27 '25
There are parts of the US where shared rooms are pretty common. Mainly in bigger cities with older hospital buildings.
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