# private insurance, public hospital



## kdsb (May 3, 2015)

We have DKV private insurance for our family which has generally been working out well for us for basic childhood stuff (broken arm, ear infection, vaccines, etc.). However, my 10-year-old son has had a stomach ache for almost 3 weeks now and the pediatrician we see has exhausted every test to try to find out the reason. He has suggested that the next step will be to visit a public hospital where there are more specialists available. 

I have heard very mixed things about how visiting a public hospital will work with our insurance.
1. Our pediatrician seemed to suggest he could refer us there by filling out some paperwork, and didn't mention any payment involved in this. Of course by the time I had mentally translated everything he had said the appointment was over so I couldn't press for details.
2. I have heard that public medical care is available for free for all minors.
3. Our insurance says that because it out-of-network we will be responsible for 20% of the bill and they would reimburse the other 80%.

Obviously I trust #3 the most since it is directly from our insurance company, but I have no idea what kind of bill to expect. I'm fine paying 20% of a $200 bill, for example, but not a $2000 bill. Though perhaps being from the US my ideas about the cost of health care are skewed.

I am guessing he needs to see some sort of stomach specialist and maybe get further testing, but someone suggested that I just go to Urgencias at the public hospital for this. Which isn't usually how it would be done in the US since it's definitely not an emergency, but maybe that's how they do it here?

I am hoping this all clears up over the weekend and I won't have to deal with it next week, but I want to be prepared and know what my options are. Even though my Spanish is pretty good, navigating a different health care system combined with a bit of a language barrier can make simple things seem quite complicated.


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## kalohi (May 6, 2012)

I only have limited knowledge about this, but since no one else is stepping in with advice I'll give it a go.

I have a neighbor who only has private insurance, and her 3 year old son had an emergency situation that a private hospital could not deal with. After many hours of wading through bureaucracy the private hospital managed to transfer of her son to a public hospital, where he was operated on and cared for for free. 

This happened in Andalucia (not where you're living) and it was apparently a life or death emergency. So the circumstances are different and may not be applicable to you. But it does show that it can happen. 

I also know of a case of an adult with only private insurance who went to the ER of a public hospital. She went there because it was the closest hospital and speed was of the essence. They treated her no problem, but then she received a bill in the mail for the whole thing. (I don't know how much it amounted to.) Her private insurance company refused to pay any of it. 

Again, the circumstances are different since you're dealing with a child. You're right in thinking that minors are supposed to have free healthcare in Spain, but I've heard that it can be hard to make work. 

I can tell you that if you go to the ER and it's not a true emergency requiring hospitalization they will treat the immediate symptoms and send you on your way, saying you should follow up with your GP/pediatrician. They don't make referrals to specialists. The only access to specialists in the state system is through your state GP/pediatrician. At least that's how it works in Andalucia. 

To me it sounds like the best bet for you is number one on your list. 

I'm not sure if any of this helps, but I don't have any more experience with this.

I hope your son feels better soon!


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## kdsb (May 3, 2015)

Thanks for the info. I did some digging through the public hospital's website and found a pediatric gastroenterologist, which is I'm guessing what the next step is if this doesn't resolve itself soon. So I think I will go by there on Monday and take whatever the next available appointment is. I think paying 20% of an office visit would be entirely reasonable, but was worried about what fees would be involved in just showing up to Urgencias with a semi-sick kid, which is what some Spanish friends were suggesting I do. 

I've also made an appointment for next week with another gastroenterologist who does not specialize in pediatrics, so I can try that option as well depending on how long the wait is to see the pediatric specialist, but I'd prefer he been seen by someone who specializes in treating kids even if we have to pay for it.


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## xabiaxica (Jun 23, 2009)

kdsb said:


> Thanks for the info. I did some digging through the public hospital's website and found a pediatric gastroenterologist, which is I'm guessing what the next step is if this doesn't resolve itself soon. So I think I will go by there on Monday and take whatever the next available appointment is. I think paying 20% of an office visit would be entirely reasonable, but was worried about what fees would be involved in just showing up to Urgencias with a semi-sick kid, which is what some Spanish friends were suggesting I do.
> 
> I've also made an appointment for next week with another gastroenterologist who does not specialize in pediatrics, so I can try that option as well depending on how long the wait is to see the pediatric specialist, but I'd prefer he been seen by someone who specializes in treating kids even if we have to pay for it.


You have to have a referral from a GP or paediatrician for an appointment with a specialist in a public hospital, as kalohi said. You can't go to the hospital & ask for an appointment - even when you are already 'in the system' as it were, which you aren't.

It's true that children under 18 are supposed to have full access to healthcare, but again, as kalohi says, it can sometimes be a battle to get it. A friend whose baby was born here a few weeks ago, is struggling with this atm.


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## kdsb (May 3, 2015)

xabiachica said:


> You have to have a referral from a GP or paediatrician for an appointment with a specialist in a public hospital, as kalohi said. You can't go to the hospital & ask for an appointment - even when you are already 'in the system' as it were, which you aren't.
> 
> It's true that children under 18 are supposed to have full access to healthcare, but again, as kalohi says, it can sometimes be a battle to get it. A friend whose baby was born here a few weeks ago, is struggling with this atm.


Thanks for the info. Our pediatrician said we could go to the hospital and then he could do the paperwork afterwards, but it wasn't clear to me whether he was talking about the ER or a specialist. (This was the "next steps" point of the appointment where by the time I had mentally translated and processed everything the appointment was over and I didn't get a chance to ask questions.) I'll go by the hospital on Monday to figure things out. I'm sure our pediatrician would write a referral if that is necessary, but maybe it wouldn't be required since we'd be paying ourselves. Any insurance reimbursement would happen after the fact, and based on our plan, they said it would be 80% reimbursement.


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## xabiaxica (Jun 23, 2009)

kdsb said:


> Thanks for the info. Our pediatrician said we could go to the hospital and then he could do the paperwork afterwards, but it wasn't clear to me whether he was talking about the ER or a specialist. (This was the "next steps" point of the appointment where by the time I had mentally translated and processed everything the appointment was over and I didn't get a chance to ask questions.) I'll go by the hospital on Monday to figure things out. I'm sure our pediatrician would write a referral if that is necessary, but maybe it wouldn't be required since we'd be paying ourselves. Any insurance reimbursement would happen after the fact, and based on our plan, they said it would be 80% reimbursement.


I suspect the paediatrician meant that you could go to urgencias/the ER. 

I'd be amazed if you managed to get an appointment with a specialist - even if you're paying. The system here is very much one of referral.

Let us know how you get on - though hopefully it won't be necessary :fingerscrossed:


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## kalohi (May 6, 2012)

xabiachica said:


> I suspect the paediatrician meant that you could go to urgencias/the ER.
> 
> I'd be amazed if you managed to get an appointment with a specialist - even if you're paying. The system here is very much one of referral.
> 
> Let us know how you get on - though hopefully it won't be necessary :fingerscrossed:


Agreed. In fact in our local state hospital there's not even anyone to talk to about appointments. The nurse working with the doctor has a list of who's to be seen that day and she pops in and out of the doctor's office calling people in when it's their turn. There's no sort of general receptionist. The appointments are computer generated at a doctor's request and sent to the patient by mail. 

Another thing to consider - around here there are long waiting lists, usually several months. One of the advantages of seeing a private doctor is that you generally can get an appointment quickly. 

Again, this could just be the way the state system works here in Andalucia, so of course you should go to the hospital and see if you have any luck. As xabiachica says, fingers crossed that it won't be necessary!


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## xabiaxica (Jun 23, 2009)

kalohi said:


> Agreed. In fact in our local state hospital there's not even anyone to talk to about appointments. The nurse working with the doctor has a list of who's to be seen that day and she pops in and out of the doctor's office calling people in when it's their turn. There's no sort of general receptionist. The appointments are computer generated at a doctor's request and sent to the patient by mail.
> 
> Another thing to consider - around here there are long waiting lists, usually several months. One of the advantages of seeing a private doctor is that you generally can get an appointment quickly.
> 
> Again, this could just be the way the state system works here in Andalucia, so of course you should go to the hospital and see if you have any luck. As xabiachica says, fingers crossed that it won't be necessary!


Our state hospital does have a desk for appointments - but they won't speak to you unless you have a paper from the specialist you have just seen, stating that you need a further appointment.

I'm in the Valencia region


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## Lynn R (Feb 21, 2014)

I know someone who was treated at our local state hospital and the treatment was paid for by her private health insurer. However, she presented as an emergency as a result of an accident and was treated for that, including follow-up appointments. She was also non-resident and the insurance company was a foreign one. The hospital had an office which dealt with the admin side of things.

As others have said, I don't know of any way a scheduled consultation with a specialist working in a state hospital could be arranged on a private basis.


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## kdsb (May 3, 2015)

OK, thanks. I found info about the hospital patient intake desk so I'll go there just to find out what the process is. I also found some pediatric gastroenterologists in other cities that are covered under our plan, but I'm hoping we don't have to travel, especially if there is a need for follow up, etc.. Hopefully this will either go away on its own or the private gastroenterologist I have booked for later this week will be sufficient. I am used to living in an area where I can access pediatric specialists very easily, but maybe adult doctors for kids are fine in cases like this. It is definitely not a serious situation, but bad enough that he's been unable to participate in school, sports, social life, etc. so I'm hoping we can get it resolved soon.


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## Brangus (May 1, 2010)

kalohi said:


> In fact in our local state hospital there's not even anyone to talk to about appointments. The nurse working with the doctor has a list of who's to be seen that day and she pops in and out of the doctor's office calling people in when it's their turn. There's no sort of general receptionist. The appointments are computer generated at a doctor's request and sent to the patient by mail.
> 
> Another thing to consider - around here there are long waiting lists, usually several months. One of the advantages of seeing a private doctor is that you generally can get an appointment quickly.
> 
> Again, this could just be the way the state system works here in Andalucia,


The above description is pretty much accurate for Castilla-La Mancha, too.


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## kdsb (May 3, 2015)

Just a quick update...

Symptoms have continued so I've been looking into next steps. Thanks to the help of a friend who has a contact in the hospital, we have an appointment with the pediatric specialist there in a few weeks. We will have to pay but our insurance will reimburse part of it so it's not an unreasonable cost (about 70 euros for first appointment and 15 for follow ups). We don't qualify for the free health care for minors since we do have our own insurance. We did have to get a report from our pediatrician in order to make the appointment. 

I also have an earlier appointment in Valencia with a doctor that is covered under our insurance, but will probably cancel that unless he gets worse since I'd prefer he see a doctor nearby for follow up, etc.. We also saw another pediatrician for a second opinion who ordered some additional tests so maybe those will provide some answers. I brought him to a general (not pediatric) gastroentrologist who practically threw us out the door after we walked in telling us he doesn't treat kids (but not before taking down our insurance information so he would be paid). So it seems like the only pediatric doctor in this city is in the public system, and I have heard she is very good, so we will just wait for that appointment. It is not an urgent situation and he been making it through the school day lately, but hopefully we can get it sorted out eventually.


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## kalohi (May 6, 2012)

I'm so glad to hear that you were able to get an appointment with a pediatric specialist at the hospital, and also that your son will be seen relatively quickly. Now let's hope that he improves in these weeks and that he doesn't need to keep the appointment.


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