[Vinerino]

Anyone have any experience working with for health industry. My brother breaks his ankle and leg, goes to emergency room at participating hospital the morning after accident. They tell him it is too swollen to do anything ...to see a doctor. He sees a doctor who is part of hospital and Oxford Health plan but not my borthers health plan. Surgery occurs within 2 days of initial visit to Emergenct=y room and should have been treated as emergency. Apparently authorization did not occur and it was not pre approved. The removal of screw....broken I moth add...were paid by insurance company.
Anyone have expertise in this area. Best I have heard is that it was "fragmented emergency room service". Oxford pays nothing if out of network. Sure wish hospital took care of ankle on day of initial visit.

[Shirleevee]

Some years ago in NY, I had a similar issue and got some help at the NYS.gov website. Your brother might want to check out his states site. Look under Health and then, "your rights for appealing decisions by insurance companies"! Good luck

[tumbleweed]

First, your brother should read the pertinent sections in his Certificate of Coverage (for groups) or his individual insurance policy concerning emergency care and participating providers. Sounds like both Oxford and his plan penalize for use of out of plan providers. For HMO and PPO plans it is critical to use in-plan providers. Some plans will pay less, and some will pay zero when out of plan providers are used. There are usually exceptions for emergency treatment, which the policy or Certificate define.

His plan documents should include a section on filing appeals if he believes the contractual terms were not followed. His appeal can be made directly to the Insurer within the stipulated time period. If his is an employer provided plan (many of which are self-insured) he can explore the matter with the appropriate HR benefit person and perhaps get some leverage. He can also submit a complaint to his state Insurance Commissioner, but such appeals are usually not effective unless the Insurer clearly violated contractual provisions.

Another possibility- see a lawyer who knows how health insurance works and is willing to handle. Sometimes a stiff letter from an attorney will cause re-consideration.

My question: Why did he not go to an in-plan MD for follow-up?? Unless there were extenuating circumstances, his plan is not likely to change their decision, and Oxford is likely to affirm that they provided the necessary emergency care and is not responsible for his subsequent surgery, etc.