Seems like it’s the season for medical and health concerns. Here’s another recent wrinkle of the question– what are a Host Family’s responsibilities for an Au Pair’s medical expenses?
I am writing because I find myself in a tough spot and our former au pair in an even tougher spot.
Our Au Pair ended her year with us a week ago and is with a new extension host family. About three months earlier, she hurt her neck – she said it was because my son (4 years old) jumped on her. I was not there to really witness it and she didn’t say anything to me at the time. It seems her neck bothered her for quite a while and she finally asked to see the doctor.
Since she never got a local doctor, I had to take her to the urgent care. Not sure how many tests they did but she ended up being prescribed a standard muscle relaxer. About a week later, when she was off duty and I was at work, she called me that she needed to go to the doctor again, that was dizzy and felt like she couldn’t move. I had to go home so I could pick the kids up from school (which she would have been doing when she started her shift) and a friend took her back to the urgent care. From what she told me, the dizzy spell was simply a side effect of the muscle relaxer. She of course didn’t work that day and seemed fine enough the next day.
Besides these two visits and the muscle relaxer, I do not think she saw a doctor further about this issue.
She recently told me in an email that her insurance is not covering the expenses. She says that they don’t believe a 4 year old could have injured her so badly and they are asking her to pay $1800 in medical bills.
I feel terribly for her and think the insurance should pay, though I did think at the time that her eagerness to go to urgent care and have a bunch on unnecessary tests done might backfire. For instance, the second visit, they did nothing for her, but probably ran a bunch of tests nonetheless. Hopefully, she will be able to work it out with them.
However, I am worried that if she doesn’t she will try to come after us for the money.
Is this something that we would be responsible for?
If an insurance company says they shouldn’t cover it, why then should we?
Hoping to get any guidance I can from the group!!
Hostmomof4
See also: Do Host Parents need to buy Workers Compensation Insurance?
{ 22 comments }
As the parent of a child with special needs I have extensive experience in appealing claims. Your AP will have to appeal the insurance company’s decision. She may not succeed, but she will never know until she tries. I don’t know whether the bill arrived before she left – and you could have filed the appeal together, but she will have to telephone the insurance company and ask how to file her appeal.
Our LCC warns every AP upon arrival while that going to the ER or other urgent care is something they might do for a non-emergency in their country, they should not do that in the United States, because their AP insurance policy will not cover it. Since it was your decision for her to go to urgent care, rather than she should mention that as part of her appeal process. Since she let the pulled muscle go for some time before complaining about it, the insurance company would have decided against it’s being an emergency and something that could have waited until the next available appointment with a physician. If she ends up filing a paper appeal, then a letter from you explaining the situation might help.
Put the onus on her to file the appeal. She should absolutely not attempt to pay the bill, because if the insurance company rejects her bill, then she should contact the urgent care facility to see if they will reduce their bill. If she follows through and does these things, then my advice to you would be to pick up the tab for what’s left.
Do not encourage her to abandon the bill without attempting to deal with it. While the urgent care facility probably can’t follow her home – a debt that size could have a negative impact on returning to the U.S. in the future.
You should definitely NOT pay for it! If i was your aupair i certainly wouldnt have went for a stiff neck!
However I went to urgent care the other week after my host parents persuaded me and ended up in the ER. I have no idea what my bill is going to be especially since hers was $1800.
My host parents did offer to help with the costs but obviously Im not going to let them as they don’t have a lot of money and 3 babies to pay for.
Tell her to definitely appeal! My hm is doing appeals all the time (she has chrons) and spends alot of time at docs/er.
Hope everything works out for her and you! Definitely don’t pay though! I feel her excuse was poor and a child would have done so much damage she needed to go to docs
One of the challenges I have with the AP program is when APs make less than ideal decisions (urgent care vs seeing a regular doctor, waiting until it impacted work vs being preventive, letting urgent run a bunch of tests, etc) and then expect host families to share in the negative consequences (insurance declinations, lost work, expensive lab bills).
I feel for any AP that is hurt here. I wish the insurance was better and explained better (only our CCAP APs seemed to fully understand their plans – it’s covered in detail before coming and during orientation). But for an AP to make decisions and then expect the HF to pay for it, that’s where I get stuck.
AP1 hurt her back (presumably wrangling our two under 3). She asked for my advice. I recommended our chiropractor. I called him, he agreed to see her, took her insurance and cut down the rest due. She felt worlds better and she paid it and it was relatively cheap (under $100 for 2-3 visits). If she had gone to urgent care and then hit me up for $1800 I would have lost it!
Yes, I’m sure there are outlying scenarios where I might pay for it but probably not without my being involved in the care decisions. I don’t see any way she can come after you for this so don’t worry about that. If it was my AP I’d offer advice (appeal, write her a letter, etc) but otherwise it’s out of your hands. If we had to cover AP medical it would take us out of the program. It’s already more for us than a nanny.
I’m not in the US, and I’m not that familiar with the rules, let alone the AP insurance rules, BUT as far as I’m aware whenever an accident happens while you were doing your job your employer picks up the tab. I also think that an energetic 4 year old might unintentionally yet seriously injure you if you’re not careful enough.
Also, I disagree with UKaupair, your HF might ‘not have a lot of money and 3 babies to pay for’ but that’s not really something you should have to think about since they decided to employ you. If something happened to you while you were on duty then either your insurance would cover the necessary treatment or the HPs should.
When an employee in the US makes a claim of a work-related injury, there is a pretty onerus process undertaken to review the claim and ensure that is was truly work related. In this case, the injury in question would most likely be rejected by workers compensation insurance because of several factors, not the least of which is that she had been complaining of neck pain for some time and it seems that only when she got a bill did she decide to pipe up and blame the kiddo.
In addition, in workers comp cases, the paying party (employer) determines what type of care is sought, what tests may be run and what therapies administered. This is both to track the progress of the injury and to control costs. It doesn’t seem like the AP gave the HF that option and she chose to go the most convenient (aka expensive) route for her.
I’d suggest that the AP appeal it with the insurance company as discussed above and also call the urgent care clinic to offer a small – but rapid – payment. They likely aren’t charging her for any significant hard costs and will be happy to get what they can. My insurance pays 5-10% of the rack rate for lab work and about 30-50% for the doctor’s time. The urgent care clinic isn’t charging the insurance company $1,800 so it’s not unreasonable to offer less than $1,800. My coworkers have done this so you don’t even need to be low-income – just call them on their bluff about the $1,800.
Beyond that, I wouldn’t worry about it. A 4yo is unlikely to have caused much real damage. The clinic ordered all the tests knowing better than anyone what was likely to be covered – let them worry about who gets paid what.
This is tough, and I don’t fully understand the American health care system, apart from that it seems horribly expensive. I think it’s a question of a few things: it was on the job that she was injured. Who decided on urgent care, in the end? And when that decision was made, if it was by the AP, did you, as someone who understood the system, explain to her that this kind of issue might arise? I wouldn’t have thought of it, because I come from a place with universal, free health care and think of free health care as a right.
As it happens, I *wouldn’t* go to urgent care for a stiff neck, and do have a fairly healthy irritation with those who overreact (I was once held up in a queue at accident & emergency, bleeding so heavily I ended up fainting on my friend while *in* the queue, and had to spend that time listening to the girl in front of me describe a “funny feeling” in her wrist that “didn’t really hurt… It just kind of felt a bit strange, and clicked when she turned it…). But as I understand it (could well be wrong), in the US, health care costs an awful lot, so a lot of people ignore small issues until they become big enough for urgent care? Or else it’s only urgent care that’s covered? Are there mitigating factors in the decision to go there?
As it is, with the info we have, I’d say it might be the right thing to do to pay some of it. If you warned her at the time of the costs involved in going to urgent care, and did everything you could to get her access to more reasonably priced treatment, then it might be justified to just pay the amount she *would have* been charged if following your advice. If it was more of a “I thought it might be an issue, but didn’t want to say so” thing, then I think you might have to pay up. She got injured on the job, after all. And was a stranger in the only developed country left that doesn’t have some form of subsidised health care, in a job that doesn’t offer health insurance that covered her work-related injury…
But yes, I agree with all the others who say that she needs to appeal the decision and jump through all the hoops and make herself a bother as much as possible.
Having said that, the health insurance my HPs bought for me here nearly didn’t cover a routine GP appointment, and I didn’t expect them to pay for it (having already bought the insurance..!). But that was like, 20E or something, and anyway, in the end my Host Mum rang up the insurance company and excoriated them until they fixed the issue. :)
Not sure if it matters but I do not know if it was on the job or not. She didn’t tell me it happened for a week or when it was specifically when it happened so I am not sure. And she isn’t from a “developed country” she is from Mexico who has just had universal coverage for 3 years (2 before she came). And she does have health insurance (same company as my own, though probably with not as good coverage) and the urgent care center she went to accepts that insurance. So, its not a matter of her not having health care insurance or coverage. The insurance company covers this type of injury – they are saying the treatment she received was unnecessary.
As for what I told her, I asked her if it was absolutely necessary because a neck sprain usually resolves itself. I had given her bengay and ibueprofen. I warn her about these places because the wait is long and you never know what tests will be covered. But on the other hand, I don’t have other immediate suggestions for her other than the ER which is even worse. This is where the LCC directs everyone in our cluster so that’s where she went. I would have investigated free clinics but they are probably much further away and those are more for people who don’t have insurance – she does.
This extra information helps. In her appeal, she should have the LCC write a supporting statement that she directed the AP to go to Urgent Care. Put the onus on the AP to follow up, and as I stated before: first file an appeal and if that doesn’t work then work with the Urgent Care facility on a fee reduction. Remind her that you suggested that she probably had a pulled muscle which would resolve on it’s own and she choose to seek immediate care. The onus is on her.
That being said, should she successfully come to a resolution that brings the price down to a more reasonably level, I’d offer to share in the costs, as a good faith gesture that the “injury” actually did occur while she was caring for your child.
I’d like to circle back to a line from the OP: Since she never got a local doctor, I had to take her to the urgent care.
In my experience, APs do not see local doctors. Most see their physicians when they depart. If they need birth control pills, then they go to Planned Parenthood, which provides exams and medication on a sliding fee scale (that’s where I went as a young adult, until I earned enough money that it was cheaper to use my health insurance).
Nevertheless, APs don’t need to go to the ER or Urgent Care when they have routine illnesses just because they don’t have a GP in the U.S. For routine illnesses, they have several options – go to a free clinic and hang out and wait to be seen, go to the CVS “minute clinic” (other national drugstore chains may offer similar options) – great for the rapid strep tests, colds, etc.; or the after-hours clinics that are opening up in many American cities (we found one near Las Vegas when The Camel tanked there – much cheaper and faster than taking her to the ER).
Our LCC has links to some of the local options on her Blog home page, which has been helpful to us when APs get ill. I took an AP to see my G.P. once – but it was really expensive compared to the CVS minute clinic for the same amount of time and end result.
Finally – for APs from countries with nationalized medicine – and that’s just about the rest of the world, isn’t it? Navigating insurance reimbursement can be tricky. While DH and I send APs out to get several things on their own: social security cards, bank accounts, driver’s licenses, he does help them file claims and seek appeals. It’s a crazy system in the “for profit” medical world.
This is the OP here. To clarify, this urgent care center is the place where the LCC directed us to go. This was not our first time there – she had to go on her third day with us and after, I warned her that these places might do a bunch of tests that aren’t covered. I went on and on about how convoluted the system is so she knew right from the very start. I do not know of any free clinics near us or minute clinics so we went where the LCC directed her to go. And each time, I asked her if it could wait, could she make an appointment, for a few days later, and she said she thought she should be seen immediately. Given all this, it was my au pair’s decision to get urgent treatment – not mine.
As for her own experience, she is from Mexico (not from a wealthy family). I think Mexico has universal coverage now but its is somewhat recent (since 2012) so I don’t think she is operating under the assumption that you can get all the medical testing in the world plus prescriptions for free/very low cost.
My whole thing with this is that she has health insurance that would cover such an injury. What they seem to be saying (or at least how I am hearing it from her) is that they don’t think the treatment was necessary. And if that’s the case, do I then pay for unnecessary medical care?
Lastly, she did end up getting a PCP because she discovered she had an ongoing issue that needed follow up care (not related to the injury at all – an GYN issue) but only then, when the problem wasn’t urgent, did she finally make some calls to network doctors and find someone local. So, they can get PCPs (and I would recommend they ALL do).
It’s not your problem that the insurance company is denying the claim, therefore you should not be responsible for paying the bill. I would not be paying for unnecessary medical care. She is an adult, ultimately made the decision to follow through with going to the urgent care center and now should deal with the consequences.
I handle dozens of complex medical insurance claims a year for (extended family). It is common for clinics and doctors offices to not put sufficient dx codes or office notes in the file/medical claim. Sometimes for example a claim will be refused with similar reasoning to that given to OPs AP. So far we have eventually had it paid by insurance by finding a nice manager at the clinic or doctors office to resubmit the claim with all the possibly relevant codes and/of office notes.
For example the dr may have just submitted the claim with the DX or ICD9 code related to a minor muscle issue which would maybe not have justified to the insurance doing some additional tests the AP had done. So for example if she was dizzy there should be a code in the record or claim associated with vertigo or dizziness which would explain and justify additional tests. The point is, make sure the insurance company is given the complete picture by the clinics claim file. I often end up hosting a 3 way call between clinic insurance and myself to mediate the flow of info. Bottom line I point out to them is that the contact on what is a covered amount and what are the right or permitted services for a given DX or suspected DX is governed by a contract between the clinic and insurer. They need to talk to each other. Honestly this sounds like a case of a lazy or untrained billing office at the clinic the AP visited. They should reexamine and rebill the insurance. But first get an understanding of whatever extra codes and info the insurance needs.
This will probably take hours of time on the phone with clinic and insurance.
I am not an insurance expert. Just somebody who has accepted that insurance medical claims of my family will take many hours of my life every month!!! But persistence brings payments!!!
The key word here is persistence. Caringhp and TACL’s advice is right on. My sister had a disabled daughter and often had rejections by the insurance company that were reversed under appeal. It often seemed that a rejection was automatic. If the diagnosis needs to be clarified or expanded, the clinic can help and they may also be able to reduce any amount left over after the insurance pays out (and likely even more if they don’t). The burden is really on the patient to pursue it and the AP should definitely do the legwork, but I would also offer to help cover a portion of what’s left as a good faith gesture, particularly if you hope to use this AP for a reference in the future.
I do not think you should pay the bill for items the insurance company refused to pay after you warned about this very scenario whether it occurred on the job or not esp since is not the course of treatment you would have picked. The impulsiveness drives me crazy sometimes. I pay our aupair’s deductible if they have to see a doctor and put a bit of money towards the antibiotics but that is it. Our last aupair had a horrible UTI, I went through the insurance paperwork and found they had a telenurse. I called the telenurse and asked her advice, she advised going to a family practice doctor as soon as possible. I found numerous ones in their network a few miles from our house and had her set up an appointment the next day. I loved the idea of the telenurse. The antibiotics worked great. The issue that did bother me was that they did want to see her for follow up but that would have incurred another $50 co-pay which I thought should have been included in the course of treatment. I offered to pay the co-pay again but she did not want to go back. It all worked out fine. It was a positive experience asking the advice of the insurance company.
I don’t have anything useful to share, except to say that I stand in awe of the wealth of knowledge here on the limitations of AP health insurance, the costs and services of urgent care, and the process of filing claims and appeals. I personally have very comprehensive medical insurance and, while I know generally that AP insurance is “not good”, I don’t think I would know how to steer my au pair to the best, low cost options. I certainly would never guess that going to urgent care could result in a bunch of unnecessary tests being run, and that insurance might deny them. I can only recall going to urgent care once, with my son, and they actually sent us on to emergency because they didn’t have sufficient equipment to run the necessary tests (they thought he might have appendicitis). We did use the Minute Clinic a couple of times when he was little and got pinkeye– I thought it was a great solution.
Anyway, I’m grateful to this site for once again filling in the enormous gaps in my knowledge! I have to say, I don’t understand why AP insurance has to be so bad. Aren’t they the age group with the least risky health profile? It seems for a little bit more, they could have vastly better coverage ($50 copay for an office visit? Seriously??) At a minimum, the agencies should do a more thorough job of advising au pairs how to navigate the health care system. It’s not enough to say “this is going to be really expensive”; rather, they should say “if this happens, this is who you call; this is how you file a claim; this is what you can do if your claim is denied, etc.”
I have a lot to say about this, as I work in a health care job.
A few points: usually, urgent cares bills are almost identical to primary care bills. There are some “free standing Emergency Rooms” that look a lot like urgent care – but bill like an ER. If your AP goes to an Urgent Care, you should make sure that Emergency is not in the name. The cash price for an UC visit should be $1000, on average, for an ER).
All negative tests are unnecessary, in retrospect. Without having been in the room with the AP and the physician, let’s not speculate about how inappropriate the evaluation was. I am very confused about why the insurer is arguing about whether the injury could have been caused by a four year old – they are obligated to cover necessary medical care, whether it happened on the job or not (unless the OP is using some kind of worker’s comp or homeowner’s insurance to try to pay for things.) Are they implying that it happened while roller blading and is therefore not covered? As long as it didn’t happen during some kind of forbidden activity (i.e. snowboarding, parasailing, etc), they should be covering the medical evaluation.
There is no legal (or in my opinion, moral) obligation for the HF to pay medical bills. Unless you have control over the situation, you shouldn’t be held liable for choices made. To be honest, what will happen in an AP has unpaid bills? They will be referred to a collection agency (at worst). The collection agency could call her a lot, if they could find her. Her credit could be ruined!!! But, she already has no credit. An AP can’t get an iPhone without a $500 deposit — because AT&T knows that they have no way of collecting on any debts. The UC/ER can send a lot of letters, but they have very little power to do anything else.
OP here: That’s a fair point. In my telling her they might run a bunch of unnecessary tests, I was just repeating what I hear from others as I myself have never been to an urgent care clinic. Nevertheless, here she is with a bunch of bills that aren’t being covered. Someone above mentioned that they might not have coded things properly and sometimes without the exact right code, insurance doesn’t pay. I have never had to deal with an insurance claim so I am not much use to her. And she didn’t tell me about the bills until after she left so I’m in even less of a position to help.
As for why they won’t cover it, I am surprised too. Do they think she lied and went to the doctor for no reason? The first time, she did get a prescription so there was definitely a strained muscle there – I can’t understand why it matters how it happened. Unless she misunderstood the insurance company. She went to the urgent care a second time, and maybe its that visit they don’t want to cover? There was nothing wrong, just a bad reaction to the muscle relaxer, apparently. Additionally, she went to the ER twice in that same month for a GYN issue so I am not sure if the $1800 is from all of her various visits or just the ones related to the neck. She made it sound like it was all because of the neck stuff but since I haven’t seen the bills, I would know for sure.
On a tangential note —
Do you realize that some (APIA, CC) insurance excludes any problem that occurs while drinking alcohol? Even if no illegal act occurred?
A friend of an AP was wearing high heels on NYE and fell, cutting her face. She had an ER visit that involved a blood draw (noting a + alcohol level) and then some stitches. They refused to pay any of the $3000 bill (or so I heard through the grapevine).
When extension paperwork came through for my current AP, I actually read the insurance documents and found that they exclude all injuries or medical problems that occur as a result of alcohol – even if legally used (below the drunk level, age 21+). That’s crazy and really unfair. Adults are allowed to be intoxicated in the US and they should not be financially devastated by that decision when they have insurance approved by the (federal?state?) insurance commissioner.
If you have an AP with an urgent (not emergent) medical problem after using alcohol, I would consider waiting until she was sober-ish to get medical treatment. Stitches need to be placed in the first 24 hours post injury and an ankle injury (without obvious deformity) can wait 24 hours for evaluation. There would be no benefit to telling the medical team that you were using alcohol at the time of injury. Obviously, if someone has a potentially life threatening injury (head injury, problems breathing or concerned about heart) they should go to an ER and sort out the financial consequences later. However, I think APs (and HFs when appropriate) should consider delaying care in non-emergency conditions until the AP is sober.
That’s insane.
I know that APIA insurance without the sports package denies anything they say is sports related (twisting an ankle when chasing a toddler, etc) so that all the LCC tell everyone to get the sports package.
That said, the APIA insurance has worked pretty well for our APs. We do encourage them to use a TakeCare Clinic or Minute Clinic first. But I think last year APIA dropped their dental coverage.
I have little to add except my totally opposite experience with an AP ER visit and GAP, which I otherwise basically dislike but use for extensive in China recruiting.
AP1 burned her chest with boiling water while at an Aikido workshop. It was her fault but also mine as I had given her the wrong lid for the thermos. She still shouldn’t have drunk straight out of it and would have burned her mouth. Chinese thermoses don’t keep things so hot. She waited several hours to tell us and then wanted to go to the ER to avoid a scar. We told her that it could be quite expensive and wasn’t necessary. We figured out it would cost make $100 if considered necessary and max $250 if not. Then we called a family friend who is an ER doc and he confirmed that it was unnecessary. She insisted. So we called the insurance company and learned that the nearest cvs clinic was 45 min away but the ER 1.5 blocks away was in network. They recommended the ER. She went. They gave her some cream. She insisted on Chinese medicine and we refused to drive her an hour to Chinatown to buy it but spent a lot of money at the drug store getting her some anti scar stuff.
Anyway, she had some confusion about her insurance info and didn’t have it right away. She got it to the hospital and then the insurance company twice had her fill out claim info. She got billed $100 from the insurance company but one of the bills didn’t make it to the insurance company and went to collections after she had gone home. That was a mess to deal with but the insurance company was great and got it sorted out when I called. It was basically a result of our ap being a space case and not knowing her insurance info. Now I carefully save the email from the agency with that info. In the end she only owed $100.
So, my plug for gap insurance is that they have a $100 max out of pocket per injury or illness. $250 if it involves an unnecessary ER visit. So enough to keep them from going to the doc for everything but cheap enough to go when it matters. Perfect level for travel insurance.
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