Billed out of network (long)

[mrsstats]

I recently had to have an echocardiogram. I used the same group I had used before. They are listed in my plan as In network provider. They have my insurance information on record and call me before the test and tell me I have to pay $50. Ok, no problem.

I now receive by EOB and it was billed out of network. I have a Flexible Spending account (our money which we put in). MY FSA sends me a check for $770. So I call the insurance company and they tell me it was billed out of network and I should call drs office.

Ok, call drs office. Figure easy mistake and they can correct it. Nope, they tell me that the dr who read the report was not in network until the day after my test. WTH - I didn't pick him to read my report, why didnt you use in net work dr. They will not resubmit the bill, tell me they cant.

I told them I am not paying the bill. Not my fault, I used in network provider. Haven't heard back from them, guess I will have to continue my fight tomorrow.

 

[KLAIT]

Good luck with that. I am a HR/Benefits person and we have had NO luck in having these types of situations corrected. It is illegal for any provider to change anything that is not 100%. We had one employee who had a needed surgery call the specialists office before they drove the 8 hours to the facility. Told all was a go. Got there, had the tests and found out in the process that the hospital was not in network. The dr was, but not the hospital..thank goodness he knew enough to keep checking and checking and the error was caught before the really expensive surgery. The Dr office told them all was well, but it wasn't. So, in short, they were required to pay the costs of all the tests run (big bucks) and then found a different facility that was in-network for the required surgery.

I wish you well in this fight...I am not even sure what questions I can help you to ask to help get this fixed. If you figure out how to do it, let us know..we would be grateful.

 

[Lisa loves Pooh]

Write a factual but kind letter to appeal the bill.


I had something similar when I had my 2nd child actually--I had my doc all set up only to find out after we were in the hospital and she was delivered that his hospital privileges didn't include the nursery. He didn't know, I didn't know--noone knew. (he was actually backup to our primary who did have nursery privileges but was on vacation at the time and we knew that ahead of time).

She was seen by the neonatologist on call that day--and they were out of network.

I wrote a letter to my insurer, explained my diligence in securing an in network doctor and the entire situation. I request that we be responsible for only the in network portion. And they AGREED!!!!

So write a letter of appeal.

 

[Jewel1310]

I agree with LLP. Your contract would outline an appeal process. Write a letter requesting that the claim be paid on appeal. Hopefully this will take care of it. If not there is generally a 2nd level of appeal or possible it can go the insurance regulator in your state. Appeals processes should be attempted first as that can often assist in unusual situations.

 

[lillygator]

you could appeal...it was a diff dr than the one who's practive you went to for the echo?

 

[dis-happy]

If your insurance is group ins. through a large company, contact the HR dept. Sometimes they can help get things straightened out.

 

[Blessed99]

I work for an insurance company. I would definately appeal this!! At my company, about 99 out of 100 win the appeal on situations like this!! Good luck!

 

[Nancy]

Call the insurance company. I work for one too and we correct claims like this all the time if the plan allows.

Ask them if there is something allowed on your policy where if you went in network and had no control over who read the reports if they can process those out of network claims as in network.



It all depends on if your plan allows this one. There are some that will process those claims solely on the network status of the actual provider on the claim, some will allow the exception. It's a very easy fix if they allow it.

 

[scrapquitler]

I had the same thing happen to me once a long time ago....I was having surgery, at my in-network hospital, by my in-network doctor. And I ended up with a more than $800 bill for the anesthesiologist, who was NOT in my network. I complained forever, I wrote letters, I went up the chain of command, but the insurance company never would pay it. I kept saying to them "But I didn't pick this anesthesiologist, I was never given any choice about what anesthesiologist was on duty that day, etc. but never managed to get any satisfaction and eventually I had to pay it