AboutMerry Schiff Expertise I am very familar with Medicare and general insurance questions. I can answer general questions about HMO's.
Experience I have been in the medical billing industry for 50 years. I have helped develop software for this industry. I am a consultant to billers and the medical profession.
Organizations I am the Executive Director of NEBA, a medical billing organization with nearly 1000 members.
Education/Credentials I have been teaching medical billing for many years as well as being a published author with Pearson Education. One book on medical billing (nearly 800 pages) and one on HIPAA.
Question My family lives in NYC, my mom is 70, she and my Dad were in Atlantic City, NJ for a few days, in a hotel/casino.
While watching TV in their room my mom had a coughing fit and felt she had to spit, or cough up phlegm, so she went to the bathroom and when she spit, it was bright red blood.
It was more than once she coughed/spit up this blood while in the bathroom, so she told my Dad to call an ambulance.
When they went down to the front desk/lobby area to wait for their ambulance, hotel management and security documented the 'incident' and also called an ambulance.
My mom was holding a washcloth to her mouth and there were obvious bloodstains.
At the emergency room, she was examined by a Doctor, he decided to do a bronchoscopy and a CAT scan to determine what was causing the bleeding, and if it was in fact in the lung.
The Doctor decided to admit my mom and she spent a few days there while these tests were done and she was observed to be stabilized-no more bleeding.
OK, so now the 2 hour drive home and all is well, but the day after arriving home, more blood (red) coughed up.
She goes to a local hospital and again, after examination, the Doctor orders her admitted and orders the same two tests, a bronchoscopy and a CAT scan. she spends 4 or 5 days there and is now home.
HIP says they won't cover the NJ emergency room visit and admittance and tests because it was a 'non-emergency' situation.
A 70 year old woman coughs up blood, is taken to an emergency room should just be sent home?? Not an emergency?? This happened in 2 different states and 2 different teams of Doctors decided to admit her and order the 2 identical tests, to me it shows corroboration of the first teams medical diagnosis. Its not as if she asked to be admitted. Coughing up bright red blood, should she have just driven home 2 hours on the highway??
I could see if one or the other emergency room Docs didn't feel admission and tests were necessary, but since both hospitals decided the same, doesn't it prove this was an emergency? And serious? When is coughing up blood not an emergency?
So, what do we do now?? What is the appeal process?
I should add my mom is a retired Surgical PA, with 24 years of OR service and post surgical care experience so her HIP is from that job, and I guess as a 70 year old she has Medicare.
Answer Your mom evidently has Medicare but she is part of a Medicare Advantage Program which is part of HIP. Which means that that she was out of network (unless that hospital was a HIP hospital)
You need to look at the HIP website and see what the appeal process is. You need to get documentation from the ER/hospital that this was indeed an emergency and that is why the tests were ordered and why she was admitted. Chances are they did not code this correctly.
I would say that you have a very good case. Should not be difficult to handle.
