Medical procedure + out of network providerquestion

[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!