Medical procedure + out of network providerquestion

[firstbaby]

I’m soooo annoyed. DH had a colonoscopy a few weeks ago and it’s a doctor he really likes / trusts. To get scheduled for the procedure, he had to have a telemedicine appointment with doctor, doctor submitted for scheduling, he went to office for prep kit and then day of procedure. Our insurance stayed the same the whole time. A couple weeks ago, we got a “bill” from the anesthesiologist and they said our insurance had processed the claim and we owed $4800. Based on the coverage we have had for other procedures, I knew something was fishy. I logged into our health insurance portal and it showed it was still processing. DH called the anesthesiologist’s office and the billing person said that the statement was a mistake and ignore.

Yesterday, I got an email that the claim has been processed. Log in and the bill for the anesthesiologist is over $500. He was out of network, but the doctor was in network. I am SO ticked. DH didn’t choose the anesthesiologist and that person being out of network feels really sneaky. I want DH to call the doctor’s office (doctor who did the colonoscopy) tomorrow and ask them to explain. Anyone BTDT and was anything additional worked out?

[PZMommy]

I’m soooo annoyed. DH had a colonoscopy a few weeks ago and it’s a doctor he really likes / trusts. To get scheduled for the procedure, he had to have a telemedicine appointment with doctor, doctor submitted for scheduling, he went to office for prep kit and then day of procedure. Our insurance stayed the same the whole time. A couple weeks ago, we got a “bill” from the anesthesiologist and they said our insurance had processed the claim and we owed $4800. Based on the coverage we have had for other procedures, I knew something was fishy. I logged into our health insurance portal and it showed it was still processing. DH called the anesthesiologist’s office and the billing person said that the statement was a mistake and ignore.

Yesterday, I got an email that the claim has been processed. Log in and the bill for the anesthesiologist is over $500. He was out of network, but the doctor was in network. I am SO ticked. DH didn’t choose the anesthesiologist and that person being out of network feels really sneaky. I want DH to call the doctor’s office (doctor who did the colonoscopy) tomorrow and ask them to explain. Anyone BTDT and was anything additional worked out?

I had something similar. When I had my c-section, they sent my placenta to some lab for testing as I had many issues with that pregnancy. Of course I had no clue they were sending it in, and didn't choose the lab they sent it to. I got a rather large bill for it. I called my insurance company and it was prompt taken care of.

I would definitely make some calls and I bet you will be able to win this one.

[SnuggleBuggles]

That sucks. NPR has an occasional segment on issues like this and they are so common. And hard to fight. :( link to past segments https://www.npr.org/series/651784144/bill-of-the-month
eta- there are more related when you go to the Kaiser Health Network links on there too https://www.npr.org/sections/health-shots/2021/03/26/976112513/her-doctors-office-moved-1-floor-up-why-did-her-treatment-cost-10-times-more

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[ahisma]

This is somewhat common with anesthesiologists. Depending on what state you live in, there may be provisions prohibiting it. It's called surprise billing or balance billing. https://www.freep.com/story/money/business/2020/10/30/surprise-medical-bills-now-illegal-michigan/6045348002/

[NCGrandma]

This is somewhat common with anesthesiologists. Depending on what state you live in, there may be provisions prohibiting it. It's called surprise billing or balance billing. https://www.freep.com/story/money/business/2020/10/30/surprise-medical-bills-now-illegal-michigan/6045348002/

In NC, there have often been issues specifically with anesthesiologists. At one time, basically all the anesthesiologists at a large hospital were out of network for most patients (and the anesthesiologists used the resulting outcry to negotiate a better deal with the hospital). Not sure what the current laws are about balance billing.


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[ahisma]

In NC, there have often been issues specifically with anesthesiologists. At one time, basically all the anesthesiologists at a large hospital were out of network for most patients (and the anesthesiologists used the resulting outcry to negotiate a better deal with the hospital). Not sure what the current laws are about balance billing.


Yep - there are a few specialties where this tends to be more common. Radiology, pathology, and ER physicians are common areas as well. Air ambulance is a massive doozy - they are FAA regulated and there are basically no cost controls. My kids know that there are things that I won't let the do (jump from trees, etc.) when we're in an air ambulance only area.

[Octobermommy]

Don’t call the doctor. It won’t do any good. They may not even have any say on the anesthesiologist on the case. The hospital usually assigns anesthesia to cases. If you want change I would call the hospital & ask them
To offer contracts to groups who are in network with major insurances or call the anesthesia group & talk to them about it or call your insurance. Your insurance is the one with the most power- they decide what amount they will pay in network providers.

You can call a lot of people that can do better or different but the performing doctor isn’t the one that has any control. They would likely just say “sorry”. They aren’t going to pay your anesthesia bill & they probably wouldn’t have any pull with the anesthesia office to knock money off the bill.

I’m sorry , it stinks.

[firstbaby]

Don’t call the doctor. It won’t do any good. They may not even have any say on the anesthesiologist on the case. The hospital usually assigns anesthesia to cases. If you want change I would call the hospital & ask them
To offer contracts to groups who are in network with major insurances or call the anesthesia group & talk to them about it or call your insurance. Your insurance is the one with the most power- they decide what amount they will pay in network providers.

You can call a lot of people that can do better or different but the performing doctor isn’t the one that has any control. They would likely just say “sorry”. They aren’t going to pay your anesthesia bill & they probably wouldn’t have any pull with the anesthesia office to knock money off the bill.

I’m sorry , it stinks.


The procedure was done at the doctor’s office, not a hospital. That’s one of the reasons I’m so angry. The doctor was aware of our insurance and should have either advised DH the anesthesiologist was out of network or offered an in network provider.

[firstbaby]

Thanks, everyone, for the advice and commiseration. DH was told when he called the anesthesiologist’s office about the fake bill that the most we would owe was $250. He will be busy calling the two doctor’s offices tomorrow and I will call our insurance. It’s a PPO and they’ve been great to work with so far.

[ahisma]

Thanks, everyone, for the advice and commiseration. DH was told when he called the anesthesiologist’s office about the fake bill that the most we would owe was $250. He will be busy calling the two doctor’s offices tomorrow and I will call our insurance. It’s a PPO and they’ve been great to work with so far.

I think your PPO may be your best bet - although not a sure bet. I work for a coverage plan and we did pay - but it was a matter of principal for us, it wasn't officially a covered benefit (even though we watched for it and covered it). In our area, there was only one anesthesiologist group...so we were stuck.

We tried - very, very hard - to get an agreement with some of these practices. It wasn't something they were willing to do.

[georgiegirl]

The procedure was done at the doctor’s office, not a hospital. That’s one of the reasons I’m so angry. The doctor was aware of our insurance and should have either advised DH the anesthesiologist was out of network or offered an in network provider.

Those offices always have a disclaimer that they are not responsible for changes in insurance coverage. DS1 was seeing a pediatric speciality (endocrine) for some issues. He has been going to this office for about 2 years without issue. Then one day, we got a huge bill, and apparently our insurance renegotiated their contracts with that health system and decided it was suddenly out of network. We didn’t change insurance plans, and the specialist wad the only group within 2 hours in the specialty (so it’s not like we could have made an in network choice.). I called to complain at the doctors office and they basically said it was on us. Our insurance said we needed prior approval for every appointment if we wanted the out of network specialist (but only local specialist) to be considered in network. “Fortunately,” the mistake only cost $200. But we decided we’d rather drive 2 hours to the closest academic center and see the specialist there. I was so mad the billing people didn’t say anything when we had our appointment. Our insurance was from the competing network, so I’m 100% certain the office knew but decided not to tell us.


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[JBaxter]

We had that issue when ds4 was about 2. He fell and split his chin and needed stitches. Took him to our local ER when the bill came the Er was in network but the doctors were out of network The CS rep said well the dots at x hospital are in network I explained we had no idea and it was 30 miles away and he was not even 2 at the time They did pay it on the in network schedule

[SnuggleBuggles]

The procedure was done at the doctor’s office, not a hospital. That’s one of the reasons I’m so angry. The doctor was aware of our insurance and should have either advised DH the anesthesiologist was out of network or offered an in network provider.

The 2nd link in my earlier post has some overlap. The bill the person received was significantly higher than usual simply because of how the room-in the same office they always went to- was classified. Something they had no real control over. It’s a quick read.

I never pay the first bills that arrive or pay much attention to EOBs. I’ve always found that the ones that didn’t make sense had yet to be fully processed.


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[mmsmom]

This has happened to me before and is common. In my case it was the neonatal doctor for DD’s planned c-section. Every step was approved and known about by insurance. Clearly you have no way of knowing who the anesthesia doctor will be or a choice in the matter. In my case the neonatal office was very aware they were out of network and had a process for handling. They sent a letter with the bill that basically said we don’t expect you to pay. I ultimately had to get on a conference call with the Dr office and insurance and state that I would not pay the bill and the insurance offered the Dr whatever their out of network rate covered and that was the end of it.

So I would say just let them know you will not pay beyond anything you would owe if they were in network and keep appealing or pursuing as needed. I guarantee they deal with this all the time. I think they bank on the people that don’t question and just pay it.

[Octobermommy]

The procedure was done at the doctor’s office, not a hospital. That’s one of the reasons I’m so angry. The doctor was aware of our insurance and should have either advised DH the anesthesiologist was out of network or offered an in network provider.

I’m sorry- I missed that- although it doesn’t change much of my advice. The nuances of dozens of insurances with hundreds of plans makes it impossible for your doctor to know what the anesthesiologist is in network with. Unfortunately the anesthesiologists groups a lot of times won’t sign contracts - for this reason- they can collect $500 from you. There may not even be any in network anesthesiologists for your particular insurance.

I totally believe we need more transparency in the billing before the procedure.

So frustrating. Medical billing & contracts makes me want to scream. I know Assistants that make more than the doctors on some cases bc they’re all out of network & can direct bill

[Moneypenny]

This happened with DH's colonoscopy where everything was approved by insurance ahead of time. The issue was the lab and the bill was like $700. When I got the statement of benefits I called the insurance company and they ended up handling it. All I had to say was that the the procedure, doctor and facility were in network, I'd called ahead of time to make sure everything was covered by insurance, and that I had no control over or knowledge of what lab would be used (or if one would even need to be used) and that was it. I hope you have the same luck!

[carolinamama]

It's ridiculous and happens all the time. And so often, people don't have a real choice because the care is either emergent or certain providers are the only option.

Anesthesia provider groups often serve most or all of the community hospitals, endo centers, surgery centers etc in an area and leave people with an out-of-network bill. Why? Because they can. It seriously makes me crazy. At least with transparency, we could plan and save for routine or elective care.

[petesgirl]

Insurance companies and the US Healthcare system are the greatest scams ever to be thought up. That's all.

[firstbaby]

Small update - I called insurance today and did an appeal. Fingers crossed!

Thank you everyone for the advice and commiseration. This was definitely a big lesson learned and in the future, we will ask who else will be involved in the procedure and if they are in network! I told DH this is one of the barriers to prioritizing our health! The fear of unexpected costs!