30 Second Insurance Tips©

Tip 162- UC vs ER – Part II

‘Jill’ badly injures her ankle. She’s out of town and it’s a Saturday. Wanting to avoid an ER visit, she endures the pain and waits.

Back in town on Monday, she calls her doctor. He’s booked solid, but recommends the Urgent Care facility located in the same building.

Time goes by and the insurer’s Explanation of Benefits (EOB) arrives. Mega Health System coded Jill’s encounter as an ER visit. Also based on the coding, the insurer says this was an “in appropriate use of an ER facility.” The claim is denied entirely.

Let’s review.

Jill’s doctor directed her to UC in his facility. (Multiple signs leave no doubt this is UC.) The doctor and the UC facility are in the insurer’s Preferred Provider Network. Thanks to Mega’s “up-coding,” Jill’s encounter is expensive, and uncovered by her insurer which by the way, is unwilling to intervene.

The moral: dysfunction continues in our health system. Forewarned is forearmed.

PS. Jill is having surgery on her ankle next week. Seems there are bone spurs and a torn tendon after all. She switched doctors . . . . . . but not agents.

PPS. Sorry. Outrage seems worth 45 Seconds!