Health Insurance Question

[Pennylane]

I've gone to the same OB practice for the last 3 years for my yearly checkup and mammogram. Just had my last check up on November 2nd and received a bill today for $1100 and it says it is out of network!!!

Does the doctors office not check this when I come in to make sure it is covered?? I am in shock and honestly sick to my stomach about this. It's not that we don't have the $, it's just the fact that it is happening. We just had something similar happen at the Target Clinic too. The reception is assured me that the kids flu shots were covered by they weren't , so another $150 due there. I appealed it and it was denied, going to push Target on this a little more though.

So is it my responsibility to verify this every single time I or my children go to the doctor?

Ann



Ann


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[Momit]

We had a recent situation that was similar, but involved a much larger bill. Our appeal was denied, so I filed for a review with our state insurance board. They ruled in our favor and everything was covered!

I know we won't be so lucky if it happens again so I now check our network every single time.

[Pennylane]

We had a recent situation that was similar, but involved a much larger bill. Our appeal was denied, so I filed for a review with our state insurance board. They ruled in our favor and everything was covered!

I know we won't be so lucky if it happens again so I now check our network every single time.

How do you go about doing that?

Ann


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[mikala]

I don't know that they check on intake but have received letters in the past from both my insurance company and the affected doctors office when my PCP or another established provider was going out of network for our HMO. Our insurance has a large number of members locally so I don't know how much of it relates to that vs being a lesser known plan.

I'd definitely pursue with both the drs office and your insurance.

[JBaxter]

Most DRs only check to see if you have active coverage in or out of network is your choice. Ours all changed this year too

[Momit]

How do you go about doing that?

Ann


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There was a form on our state's board of insurance website. I was surprised by how easy the process was.

[Momit]

My experience is similar to what JBax described. They check that you have coverage but don't indicate if they are in or out of network for a particular plan. I noticed that ours is going to change next year. There is one network for all of our company's plans, the difference is in the co-pays and deductibles.

[dhano923]

Generally speaking, it's your responsibility to make sure the provider you use is in network. You can go see whoever you want, but if you want it to be covered, you have to make sure they are a network provider. If you have a PPO plan, you have more flexibility in who you see.

[abh5e8]

I agree with the pps...op, I think it is your responsibility to check and see if a provider is in network. I can look it up on my insurance website.

[jerseygirl]

Although it is the patient's responsibility to check coverage, the physician's office knows what plans they participate in and usually provide notice when they will no longer accept plans as in network. Call your MD and ask if you can pay the rate the insurance company would have paid esp since you have history with them. No one should have to pay actual charges.

[TwoBees]

Generally speaking, it's your responsibility to make sure the provider you use is in network. You can go see whoever you want, but if you want it to be covered, you have to make sure they are a network provider. If you have a PPO plan, you have more flexibility in who you see.

:yeahthat: Unfortunately. :(

ETA: However, your plan should have notified you if they were making any changes that might affect the doctors you can see (so that you can double check), and the doctor's office should have notified you if they no longer accept certain plans (although sometimes their way of notifying you is a sign hanging in the office that you may or may not see...)

[dhano923]

:yeahthat: Unfortunately. :(

ETA: However, your plan should have notified you if they were making any changes that might affect the doctors you can see (so that you can double check), and the doctor's office should have notified you if they no longer accept certain plans (although sometimes their way of notifying you is a sign hanging in the office that you may or may not see...)

Yes, but that's only if the doctor was in network and now is not. It wouldn't apply if the doctor was never in network to begin with.

[AnnieW625]

My insurance started rejecting stuff because we had not marked the no secondary insurance box so I called Blue Cross (we have a PPO) and the lady said she fixed it for us. I guess companies these days like to bill secondary insurance first. Good luck op, but I think in your case because you have been seeing this doctor for sometime and never had any of these charges that the insurance should have notified you of the change.

[psimpson3-5]

Having used to verify benefits for a living, before you do anything else, I would suggest calling the doctor's office to get their NPI #. They might have different NPI #s. The practice itself may have one and/or each of the individual doctors might have one. Once you have the NPI #(s), call the insurance company and ask them to verify if the doctor(s)/#(s) are in network.

[TwoBees]

Yes, but that's only if the doctor was in network and now is not. It wouldn't apply if the doctor was never in network to begin with.

Yes, but the OP has gone to this practice for the past 3 years but only received a bill after this visit.

[Pennylane]

Ok, so looks like our insurance did change . My DH gave me a new card a few months ago but told me specifically yeah nothing had changed. Well it did[emoji35] . So now I guess I'm just SOL ?? I'm going to try and call them when I receive the actual bill from the doctors office and see if I can work out anything with them.

So bummed about this!

Ann


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[Tondi G]

Ok, so looks like our insurance did change . My DH gave me a new card a few months ago but told me specifically yeah nothing had changed. Well it did[emoji35] . So now I guess I'm just SOL ?? I'm going to try and call them when I receive the actual bill from the doctors office and see if I can work out anything with them.

So bummed about this!

Ann


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Oh that's a bummer. I would talk to your doctors office and see if they can help you reduce the charges somehow.

[Katigre]

Oh that's a bummer. I would talk to your doctors office and see if they can help you reduce the charges somehow.
:yes Ask them to pay the insurance rate. You're an established patient and billing, especially with OB's offices, is often very kind and flexible.