When a HMO Won't Pay for a OON Emergency

There's an issue that I am just sick over. I did sales seminars last fall for a regional large MA carrier. During the presentation regarding HMOs, I told beneficiaries that you can't go out of network with an HMO, "unless it's an emergency." I wrote up an elderly couple on the plan afterwards, as their $0 premium Humana plan was leaving the area. The issue is when they went out of state in late January on vacation, and the wife had an attack of diverticulitis. She was admitted to the ER and kept overnight. The next day the carrier provided a verbal authorization to the hospital (with an autho

Source of insurance-forums.net