• Northside Hospital sues local insurer for failing to pay ER claims

    By: Jim Strickland

    Updated:

    ATLANTA - A popular insurance provider in metro Atlanta is paying a family’s emergency room bill after 2 Investigates called Georgia’s insurance commissioner.

    Metro Atlantans are left with few choices when it comes to choosing a plan related to Obamacare. 
    Cherokee County couple Jeremy and Lindsay King chose Ambetter of Peach State.

    “We couldn’t survive without insurance. That was never an option,” Lindsay King said.

    Jeremy has lived with Type 1 diabetes for 24 years with no major complications before last February. When back pain and nausea wouldn’t let up, Jeremy’s endocrinologist told the Kings to go to the nearest ER.

    Jeremy King's endocrinologist is not in Kaiser’s network. The closest facility was Northside Cherokee.
    Lindsay King told Channel 2 consumer investigator Jim Strickland that she knew the facility was not in Ambetter’s network.

    “On the way up to Northside Cherokee, we looked at his insurance card. It says clearly on the back that in the event of an emergency, to visit the closest ER and that it would be covered,” Lindsay said.

    To be certain, Lindsay called Ambetter from the hospital parking lot.

    “She guaranteed me that an emergency service would be covered no matter if the hospital was in network or out of network,” Lindsay said.

    Lindsay told Strickland her husband received excellent care from hospital staff.

    “It did turn out really great and we’re so thankful for that,” Lindsay said.

    She told Strickland the care they received from Ambetter wasn’t as praise worthy. The couple received a bill from the hospital for $2,706.50.


    MORE STORIES 2 INVESTIGATES:


    “The next month we got the same bill and it said that it had been processed by insurance and insurance had denied,” Lindsay said.

    The couple were eventually sent to collections. Lindsey told Strickland she had no doubt Ambetter was to blame.

    The Kings said they spent hours on the phone and filed complaints with the Georgia insurance commissioner about the bill. The Kings said the commissioner denied their claims.

    Ambetter has an "F" rating with the Better Business Bureau for failing to respond to two-thirds of complaints filed.

    By email, Northside informed 2 Investigates that it is suing Ambetter for millions in unpaid emergency room bills.

    According to court documents, Northside claims despite what’s on the insurance card, “Ambetter Beneficiaries pay for the vast majority of those services out of their own pockets.”

    After 2 Investigates contacted state regulators, Ambetter contacted Lindsay. She said the company told her there’d been a mistake and the bill would be paid in full.

    “I was shocked, completely shocked,” she said.

    Next was a call from the insurance commissioner’s office, explaining the Kings' complaint was reviewed and Ambetter would be paying.

    When Lindsay pressed the state on the change of heart, she said the woman on the phone told her, “You called WSB didn’t you? Well, that’s when I became involved.

    In a statement, Ambetter said:

    “Peach State Health Plan is committed to ensuring our members have access to high-quality healthcare. We partner with providers to offer comprehensive healthcare services to all of our members. Ensuring provider claims are paid quickly and accurately is a top priority. If at any point we learn of claims payment issues, we work to resolve them expeditiously.

    “While we cannot comment on pending litigation, the lawsuit you reference in your inquiry is unrelated to this member’s situation. After investigating the member’s concern, we determined that the member was given inaccurate benefit information due to human error. The discrepancy was quickly resolved, and the claim was appropriately paid.”

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