Child dying? Call your insurance company, first!

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.

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6 Comments on “Child dying? Call your insurance company, first!”

  1. Mindy Says:

    Wow. that is just not acceptable. I guess I should consider myself lucky that although my health insurance isn’t exactly cheap at least they cover emergencies as if they are in network even if you go to an out of network provider.

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  2. I don’t see the connection between the ACA and insurers being difficult about paying out benefits. They’ve engaged in this nonsense for years. I had a teaching colleague 10+ years ago who had a whole bunch of out of network charges when his son was born and needed emergency care. As if he and his wife were supposed to stop the neonatologists and ask if they were in network! Does this make the NHS in Great Britain any more attractive?

    Would the state insurance commissioner have any clout in a situation like this? I think insurance companies will try to get away with whatever they can. I would be interested to know how this turns out for this family.

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  3. Dr. Roy Says:

    Emily– I didn’t mean that the ACA is the cause of these shenanigans. As you say, inscos have been gaming things for years. I just meant that under the ACA, more people have health insurance, which means more people are going to have to deal with health insurance. Having health insurance is a good thing, but it’s not a guarantee of access to affordable health care.

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  4. Maria Says:

    I have a friend who had to challenge her insurance company on every single bill she received. Every one! She got to be an expert on navigating their system and getting her way, but it took a lot of effort on her part. That is no way to deal with health care.

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  5. Anna Says:

    Let me know if I can cover that for them
    No one should have to have such an added worry

    Like

  6. Ken Says:

    Everyone seems quick to blame insurance companies in these circumstances but it’s the whole system that’s broken. How much is the ambulance company charging that it comes out to $1900 AFTER insurance coverage? I don’t know how to fix the healthcare system, but it’s clear that reforms are needed and insurance is just one piece of the puzzle.

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