If you have questions about the practices of your managed-care coverage, ask the experts at the Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
I had surgery in February on my shoulder, and a pain pump that injected medication directly into the incision was inserted. The nurse told me that after 48 hours I needed to remove the pump myself and explained how to do it.
When my mother tried to pull out the tube, it did not slip out and there was just too much pain for me to handle. I was worried about getting an infection, so we called my doctor's office for advice. Since it was a Sunday, the doctor wasn't there, so I spoke with the on-call nurse. She told me that if we couldn't pull out the pain pump by ourselves, we should go to the emergency room and have them do it. That's what we did.
Now I have a $1,079 bill from Mercy Hospital because my health plan, Blue Shield, won't pay for the services I received in the emergency room, and I am being held responsible for the claim. When I complained, Blue Shield said that it "was not an authorized visit" to the emergency room and that I could have had the pump removed during a normal office visit with my doctor. I think that my health plan should pay for these services because I was told to go to the emergency room by the on-call nurse and because I was in a lot of pain. Should I have to pay?
– Angela Turner, Sacramento
When a health plan con- siders whether it is required to pay emergency room services, it must apply what is called the "prudent lay- person" standard. If a reasonable person in the same situation would believe that not getting immediate care could seriously jeopardize the individual's health, then the condition is considered to be an emergency and the health plan is required to pay for the emergency room services.
Whenever a health plan refuses to reimburse an enrollee for care provided in an emergency room, the DMHC is authorized to refer the decision for an independent medical review.
Then an unbiased reviewing organization will make a binding decision on whether the individual medical condition meets the prudent lay-person standard.
The doctor who reviewed Ms. Turner's case found that it did meet the standard and that Blue Shield was required to pay the emergency room bill.
Keep the prudent lay- person standard in mind the next time you need to seek emergency medical care, because health plans draw a fine line between what is a true emergency and what could be safely treated by a doctor during office hours.
Be careful, or you could find yourself stuck with an unexpected medical bill.
To ask a question of the Department of Managed Health Care, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
