Do I have any recourse over this or am I screwed? (insurance related)

Discussion in 'The Okie Corral' started by RCP, Nov 10, 2010.

  1. RCP

    RCP

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    I had to take my son to the ER a few months ago. I took him to the hospital I work at, who provides my insurance and is on the list of "preferred providers" within network. I get the bill from the hospital and all is ok, but then I get a separate bill from the ER physician that is outrageous. When I question as to why the bill is so much I am being told that while the hospital itself is "in-network" the physician who saw him that night is "out-of network".:steamed:

    So basically even though I took him where my insurance company prefers I take him to I am being screwed on the bill because the physicians the hospital contracts are out of network. As an employee there I am aware that all our ER phsycians belong to the same group so it wouldn't matter which one I saw, ALL of them would be considered "out-of network". Does this seem right? Is there anything I can do?
     
  2. kiole

    kiole

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    fight it... Find someone who knows something about insurance that you know and have them help you out. Luckily my mother has dealt with medical billing for most of her life, she helps me with anything in the insurance field.

    I have run into this before and now ask, most of the time getting approval from the insurance company before hand.
     
    Last edited: Nov 10, 2010

  3. rem2429

    rem2429

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    I'm headed into the ER in a few hours to pull a 12 hr shift. That doesn't seem right to me. I don't get to bill for ER visits. The hospital does all of that. If a specialist was called to come see him, I guess that would be a potentially different story, but I'd love to know how this plays out.
     
  4. Zell

    Zell IrregularMember

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    Talk with the insurance company about it. Escalate it to the next level, then the next if necessary. Someone along the line is going to sympathize and help you fix it.
     
  5. kiole

    kiole

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    at one of the local hospitals here the hospital rents space to the doctors, therefore you actually get billed from both seperatley. There is the potential of the hospital being in-network and the doctor being out of network.

    Though alot of times the doctor and hospital will work with you in a case like this especially if your not making a ton of money. If you do have a decent level of income then your going to need to argue with your insurance company, which shouldn't be too painful.
     
    Last edited: Nov 10, 2010
  6. MrsKitty

    MrsKitty

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    You work at this hospital? Ask some one in the benefits department?
     
  7. RCP

    RCP

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    Thanks for all the replies, I'm working on it now
     
  8. sweetatergal

    sweetatergal

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    I would call your healthcare provider and question them about it as well as the HR or whoever handles the benefits at your hospital too. If you are going to a facility that is "in network" the doctors should be "in network" too. You can't pick and choose the doctor you are going to see at the ER when you go in or sit with a laptop and search every doctor that comes in to see you if they are "in" or "out" of network!
     
  9. Big Bird

    Big Bird NRA Life Member

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    I recently had a CAT scan and got several bills related to the procedure. Radiologist to read it etc. By far the biggest bill was the $1200 "facility fee." When I called the billing department and spoke to their $12 an hour customer service rep she told me it was for "the facility"... OK... I was in your "facility" for 20 minutes. Is that an hourly rate or a flat fee? A: "it's for the "facility". Q: OK, what does that mean? A: Its for the facility. A: You already said that. It doesn't tell me what I'm paying for. I paid the doctor. I paid the imaging service for the CAT scan. I paid the Radiologist to read it. I paid the lab for the lab work.... What is a "facility fee?" A: I can send you an itemized bill if you would like. A: Perfect! 2 weeks later the same people call asking for payment: Q: What is the bill for A: The facility fee. Q: What is that?

    So we go around two or three times and nobody can tell me what the hell a "facility fee" is or why I owe $1200 for being in their "facility" for 20 minutes...

    Gurantee you I won't end up paying more than $300... Done this before.
     
  10. redbaron007

    redbaron007 Some Dude Lifetime Member

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    ^^
    +1000


    :wavey:


    red
     
  11. Chuck66

    Chuck66 Traveling Man

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    Nevermind. OT.
     
    Last edited: Nov 10, 2010
  12. Carrys

    Carrys Inquisitive

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    Just a thought, but if you have no control over which doctor will treat you, and if the hospital is "in network"....isn't it incumbent upon the hospital to ensure the doctor is also in network? How can they charge you for something you don't have a choice on?

    I would carry it as far as you can, wouldn't expect to be satisfied though. Just do what you can, what is there to lose?
     
  13. Dan_ntx

    Dan_ntx

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    I would have reasoned that since the Dr. was authorized to practice in that hospital, he would be adhere to the hospitals policies.

    But all health insurance billing is designed to confuse you into a mental surrender... so who really knows. I do know that I would pay the amount of the bill to an attorney long before paying that Dr. Good luck.
     
  14. user

    user VaLegalDefense

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    Take a look at the documents you signed upon admission. Somewhere in there is a clause saying you agree to be responsible for the bills of the hospital's subcontractors. That physician is a subcontractor of the hospital. As a legal matter (in Virginia, where I'm licensed, anyway), if the hospital is "in network" then all their subcontractors are, too. They're betting you won't file suit against them. Pay the physician (your debt to the physician is a matter of your relationship - the insurance company only has to reimburse you, and is not a party to your contract with the physician). Then look up the statute in your state's code of laws and find the one that talks about the insurer's good faith duty to pay, and what happens to them if they don't. Almost certainly, you'll be entitled to your attorneys' fees if you file suit. You can also file a complaint with the insurance commissioner in your state - the insurance companies are more afraid of the commissioner than they are of the courts, 'cause he can tell 'em to shut down and liquidate.
     
  15. fx77

    fx77 CLM

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    This is a common issue in anesthesia.
    Perhaps your counter could be that this failure to participate in the program was not disclosed in advance.
    They will say it was an emergency and U would have not acted differently.

    Try to offer partial payment...negotiate.
     
  16. Carrys

    Carrys Inquisitive

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    When speaking to insurance companies, "good faith" is a nice phrase to remember.
     
  17. CBDAVIS

    CBDAVIS

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    Interesting--all the ER docs send a separate bill around here (Tulsa and area)
     
  18. faceplant

    faceplant

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    Seperate billing for ER and docs and different MDs being in or out of service is not unusual. You can try to fight it, I would. But it is also important that everyone knows everything about their health plans whats in whats out who is in who is out. Know this ahead of time to avoid these kinds of issues. Most of us just assume. Been there done that. Yes you can demand to see a different MD if available.
     
  19. Blastem!

    Blastem!

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    Consider offering 40% to the ER doc - that is about what an insurance company would pay him or her. Explain that he can choose 40% right now with no paperwork to an insurance company that is slow to pay or you will pay him zero.

    They usually take the 40%.

    Keep in mind that the ER visit is still usually cheaper than a funeral in sooo many ways.
     
  20. tadbart

    tadbart duuuuude.

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    aw man, that sucks. first off, hope the kiddo's ok. my wife is an insurance guru. she said that it's surprising that the hospital hasn't mandated that the group accept the same insurance. she even wewnt as far as to call it bad business...

    as far as what to do- she said you can file an appeal with the insurance company, but they are not obligated to reduce the bill. she also mentioned calling your local news channel's consumer reporter. those guys can sometimes get things done that one person without a voice can't.

    good luck- dealing with insurance companies SUCKS. i hear about it every day. (which also sucks, lol!)