Ok, I am so furious after just getting a bill from my insurance company for $1000.00. I am so confused with the whole health insurance thing. I have a PPO and see an in-network ob/gyn. I recently had a routine surgery with my in-network ob/gyn at a nearby surgical center (he told me I was going there and I was never given a choice of anywhere else to have the surgery). I now get a bill saying the surgical center was out of network and hence I have to pay 20% of the surgery costs!! I always knew I had to check my provider was in-network but didn't realize that any facilities that he refers me to, or any place that he chooses to send my lab results to also have to be in-network. Doesn't my doctor have any responsibility to disclose this to me or offer me options BEFORE any surgeries? It's all so damn confusing and I would love to fight the charge but I'm not sure how to. My insurance company told me there would have been no charge if I had gone to an in-network facility, but isn't that at the discretion of my doctor??
Any help or advice - any medical billers out there actually understand all this B/S?
Sorry to hear this Mel. I hope the outcome of the surgery was good at least.
I'm not sure, but I think there might be a responsibility for the provider to tell you that they are not "in network" -I know they always check here and make sure you know if they are no. It confuses the hell out of me too, though. Which I think is the point. ???
Sorry Mel, but I think you have lost according to American rules.You have to ask at every little or big procedure over here "Am I covered 100 per cent under my insurance?".
It is a never ending battle because,what was covered yesterday is not today.Ask the doctors staff and when you register at the hospital,with your last dying breath "Am I covered?". Trust no one.. What a circus I admit.
PS 20 years ago I was zapped with an extra $800(That was a lot 20 years ago) medical charge.I did all my homework, hospital and doctor covered by my insurance co for a Knee replacement operation.
I received a bill from the chap who gave the anesthesia HE was not coverd by my insurance plan!!!I had assumed my doctor surgeon would get a chap who agreed to my plan's payment.Tough luck~not so~you cannot win.
My experience is the same as JohnR - be suspicious every step of the way or you fall foul of the "out of network" experience.
Had something years ago where ex-wife had to go to the emergency room at my local hospital clinic (in network) but was treated by a doctor who was not ordinarily resident there.
Cue bill that was not covered by my otherwise fairly comprehensive insurance.
I complained but the end result was the same - had to pay up. Since then, I've been complete arse any time I go to the clinic and check that everything is covered by my insurance.
Don't know anything about medical billing other than there are a lot of people that do it that seem to take up space in the parking lot at work.
I know that we can't go with Physical Therapist A when Pt insurer only pays for Physical Therapist B. Sometimes when we order meds for people from our own pharmacy on discharge some prescriptions do not get filled because insurance will not pay for Medication A but will for B. We then have to go back to the Dr and ask for a script for Med B.
To be honest, there are thousands of health insurance plans, not to mention Medicare and Medicaid and insurers change the goalposts all the time. The Dr, nurse etc will not necessarily know them and in all honesty can't be expected to. However, when it is something as expensive as surgery, I think that the doctors office could have looked into it. They have Medical Assistants who I believe also learn about billing.
I try as hard as I can not to use doctors or hospitals as it always seems to cost more than it ought.
Mel, why is this a bill from the insurance company ???
I agree with monster that your doctor should have informed you to either check with your insurance company that you are covered, or have his people check for you. Or the hospital that you were booked into should have said something. Like Monster, that is how it works here too. My eldest was in hospital recently and we knew we were covered for emergency room visits but we weren't sure about when he was on the ward so we called our insurance company. they informed us that we were covered 100% but that we shouldn't have called because that is the responsibility of the hospital.
Anyway, the reason why I ask about this bill is that the money not paid by the insurance company has nothing to do with the insurance company but the hospital and/or the doctors doesn't it? Your bill would come from the hospital or the different people/departments in the hospital, or at least that is what happens here. We have this problem right now. We have received notification from the insurance company that they have not paid for our son's whole bill while in hospital but what they sent us was not a bill. We are now waiting for the bills to actually come through, if they do, so we can fight this because the insurance company told us we were covered 100% - therefore it isn't our problem if a doctor charges more than what they are willing to pay, which is what has happened. BUT, and this is the reason why I'm not doing anything yet, there is a good chance we will receive nothing. The consensus seems to be that this is a regular occurance and the chances are we will hear absolutely nothing else. Doctors use certain hospitals because they like them and are used to them, and where they are insured sometimes too. If they have a patient who is not normally covered by that hospital they will still use that hospital but write off any differences that the insurance company won't pay. the bills we received were from the doctors that saw our son in the hospital, not for any medical procedures done by the hospital.
If it really is a bill from the insurance company, ask them why they are charging you. If it is a notification that you are not covered 100% then you could write to your doctor and inform him that your insurance believes you went out of network but you are sure he would have informed you if the hospital he chose would be covered considering he knows your insurance details and didn't give you a choice in the matter. If this bill actually comes straight from the hospital and it does not include any doctors names, then my understanding is you have to start paying this, even if you are going to fight it. Just offer the hospital a minimum payment plan while you get this sorted with your doctor. that way, even if you don't win the fight, you have at least kept the hospital off your back.
Good point, Ben. If the insurance company refuses to pay a portion of it, they just don't pay it, then the hospital/whatever bill you. There's no reason to be getting a bill from your insurance company. ???
Unfortunatly this comes under the *you should ask catagory * as you had used this doctorbefore you assuumed (im assuming ) that the hospital he sent you to was covered by your health provider . vnot always so sometimes the hospital hops out of the system that it was part of before . or the insurance drops them .
it is your responsiblilty to cheeck before having any procedure done if it is covered as this *i presume again * was not an emergency you had time to call your insurance co direct and get the info you need **from the horses month so to speak ** .
I know that type of doctor for ladies is very personal but as he seems to only operate from one perticular hospital "most doctors do " it might have been nessasary for you to change you physican to one who uses a facilility that is covered by your insurance co ....
you will have a fight on your hands to get this covered i wish you luck it will be long and frustrating but stick to your guns and you should have success .
take the approach that was the ONLY CHOICE YOU HAD,get your doctor to say it was nessasary to be done at that FACILITY and you are on the way to getting at least some of it covered by insurance . I had a similar incident a few years ago took me 2 years to get the case settled .
good luck MEL we miss your regular contributions to this board .
good luck to you
The problem is in the case of an emergency or semi-emergency when you're in not fit state to ask from the operating table 'are you in network'....
Unfortunatly this comes under the *you should ask catagory * as you had used this doctorbefore you assuumed (im assuming ) that the hospital he sent you to was covered by your health provider . vnot always so sometimes the hospital hops out of the system that it was part of before . or the insurance drops them .
it is your responsiblilty to cheeck before having any procedure done if it is covered as this *i presume again * was not an emergency yopu had tiem to call your insurance co direct and get the info you need **from the horses month so to speak ** .
Mel, first make sure this is a bill they are expecting you to pay and that it is for what you think it is for. We have found that "statements" look exactly like bills and are usually wrong. It often ends up completely different (and still wrong roll) when the actual bill comes. Also, if you are due to pay a % of the cost, this bill should come from the provider, not the insurance company. So check who it's from and exactly what it is for and why they are sending it.
Then, when you do end up with your final bill from the provider, talk to your doctor's office and ask why they insisted on this out of network facility. you may find that they can either find a reason that will satisfy your insurance company that there was no in-network option or that they have links with the facility and are able to persuade them to adjust your bill. Do not give up hope and do not pay until you are happy that the cost is fair and accurately represents your liability.
Any time you are referred to a specialist or clinic or whatever, check with the PPO as to coverage, and take notes of the phone call, date, person spoken to, and Q&A.
Most PPOs issue directories of doctors and hospitals that are in-network, but check on current status.
The hospital does have the responsibility to get permission for certain procedures, but that is given without regard to network status.
The only other advise i could add is to speak to your HR department, if you got your coverage via your work. Its been my experience if you speak to the insurance company direct they give you the run around, but when HR department gets involved things seem to start moving in your favour.
Hate insurances company's, especially medical ones lol. When I had my back surgery I asked for a detailed breakdown of the bill. Went through it and made them take a whole bunch of shit out I never had or was totally a waste. I argued that for someone to pick up my xray was not worth $150 they tried to charge me, but should be included as part of the procedure as a whole, surprised they did not try to charge me for each breath I took lol.
Good luck