Can an insurance company legally do this?

[Kitty 34]

Drop all of our doctors and our hospital we use without any type of notification to us??

We have seen the same docotors, had the same routine tests, gone to the same hospital with the same insurance for over 15 years.

Last week we got a bill on on my mammogram from the hospital. DH calls our insurance. That's when they inform us that all of our medical things are no longer in network as of last January!!!! The lady tells DH our doctors should have told us.

I call the billing lady at our doctor. They were never told.

Call insurance back. Now they are telling us my DH's job should have informed us. Call DH's job......lady I talk to says they know nothing about some switch??!!

Meanwhile.........we have NO doctor, DH has a bad heart condition, I have some medical issues. WTH are we suppose to do now? Of course the Insurance company said they will quickly mail a list of doctors (and hospital)they DO cover and all the forms that we need to fill out to make a request for a new doctor.

I just can't believe this is happening?? We live in a little town and like I said have had the same doctor for years!

 

[MIGrandma]

I have no advice, but just wanted to give you a

I hate dealing with insurance problems. No fun at all, I know.

I do hope you can get things worked out to your satisfaction, and soon!

 

[Christine]

I find it hard to believe your doctors did not know but anything is possible.

Doctors and insurance companies negotiate together for contracts with each other. For them, there is also a plan year. Prior to the plan year this past January, there should have been some negotiations between your physicians/hospitals and the insurance company. It just seems odd to me that an insurance company would arbitrarily drop a bunch of physicians and a hospital.

I know they do drop them but it's usually when the insurance company and the doctors and/or hospital cannot negotiate fees to everyone's satisfaction.

 

[Abbie]

I'm not sure what you can do about the switch since they are within their rights to do that. If they did nothing to notify you, however, I would contact your state insurance commission and find out what your recourse is as far as the bills you've incurred. Sounds like you are getting nothing but a run-around from the insurance company. There's no way they could have changed the policy like that without someone in your husband's office signing off on it, they must have been aware.

You should be able to go online to find in-network doctors, you don't have to wait for their list. Ask around for references, start by asking your old doctor if he had anyone on the list to recommend. Make your appt, and transfer the last year's worth of records to the new doctor asap.

As far as the doctor's office being aware of this, there is no way their office can know if you are in their network unless they actively don't take your insurance. But it sounds like your insurance didn't actually change, just the in-network/out-of-network part.

You can also find out from your insurance how much out of pocket it will cost you to remain with your doctor, although it will be expensive so probably not a good option. I'm sorry you're going through this!

 

[mjkacmom]

It's been my experience that the doctors drop the insurance. I've lost many doctors throughout the years, but I've always learned about it when I tried to make appointments (although once my pediatrician gave me the heads-up at an appointment).

 

[Christine]

There's no way they could have changed the policy like that without someone in your husband's office signing off on it, they must have been aware.

Actually, when I was administering health benefits for a small private company that I worked at 3 years ago, they often dropped doctors without informing the company. We never knew about it, nor had to approve it. We participated with Blue Cross/Blue Shield. That had their "network" of doctors and those network doctors were "negotiated" at all different times and dropped in and out randomly. Because I live in a city and we have tons of doctors and people, it's never a major deal because there is always someone else on the plan. But I can see how devastating this can be if you live in a small town area.

 

[Kitty 34]

But it sounds like your insurance didn't actually change, just the in-network/out-of-network part.

That's exactly what happened!

Apparently from what I'm understanding, PHP (our insurance co) dropped the hospital and everything affiliated back in January. Our doctor's office in our small town is affilated.

I just don't understand why we were never told and I guess who was suppose to tell us??

I would have thought PHP would have sent us a letter saying they would be dropping so and so within a month and here's a list of covered doctors so we could make the "Preferred Doctor" switch. Heck I would have waited on my routine mammogram if I had known any of this!!

 

[golfgal]

It's been my experience that the doctors drop the insurance. I've lost many doctors throughout the years, but I've always learned about it when I tried to make appointments (although once my pediatrician gave me the heads-up at an appointment).

I agree-usually it's the doctors that drop the insurance not the other way around. The insurance companies WANT the dr's in network but often the Dr's don't continue to participate for whatever reason (usually the negotiated rates are too low). It would be the dr's responsibility, and YOURS, to keep you informed. My guess is something was sent out and if you are like me, I didn't read it because it looked like junk mail.

 

[Kitty 34]

I agree-usually it's the doctors that drop the insurance not the other way around. The insurance companies WANT the dr's in network but often the Dr's don't continue to participate for whatever reason (usually the negotiated rates are too low). It would be the dr's responsibility, and YOURS, to keep you informed. My guess is something was sent out and if you are like me, I didn't read it because it looked like junk mail.

I thought the same thing that something was probably mailed out and we just thought it junk mail. (DH is good at that one ) but when I asked PHP why they didn't mail anything they said it wasn't up to them to inform us of the drop. Their words.

When I called the doctor and asked why they didn't mail anything....they said they didn't know that PHP was no longer covering.

So at least I know nothing was mailed and thrown away.

 

[NHdisneylover]

Op--I really do hope it is all a misunderstanding of some sort and your visit (and subsequent ones) can be covered This sounds like a nasty surprise.

I am far from an expert, but here is how i have always understood it to work:
Most of the time doctor's offices are pretty good about informing people when they change who they work with and about verifying coverage for patients at least yearly and often quarterly or at every appointment. They do this as a nice customer service thing AND to guarantee that they will get paid. However, from what I understand, neither they nor the provider is required to =directly inform me (the insured) when the network changes. It is MY job to verify that the doctor I am seeing is still in Network. The insurance company has to make that information available (via internet, 800 number, etc). Now, I am just as guilty as the next person of just glancing at the list each year at open enrollment and counting on the doctor to inform me if anything changes during eh year--but technically I do not think you have a legal leg to stand on as far as expecting that someone would have notified you. For your sake I hope I am wrong though.

 

[golfgal]

When is your open enrollment period for benefits and did your plan change with the last one--not the company the PLAN itself?

 

[allison443]

That's exactly what happened!

Apparently from what I'm understanding, PHP (our insurance co) dropped the hospital and everything affiliated back in January. Our doctor's office in our small town is affilated.

I just don't understand why we were never told and I guess who was suppose to tell us??

I would have thought PHP would have sent us a letter saying they would be dropping so and so within a month and here's a list of covered doctors so we could make the "Preferred Doctor" switch. Heck I would have waited on my routine mammogram if I had known any of this!!

Did you have to give your insurance info when you went for your mammogram? I do. If you did give them your info, I think they should have told you at that point (don't know if they legally have to, but it would have been helpful!)

I also don't believe the billing people at the doctor's office didn't know they have been out of network since January. How could they not know? They do the billing!

 

[R and C's momma]

With a small town, check to see who your closest In-Network provider is. If s/he is more than x amount (unsure of what this number would be, you will have to check back with your carrier) you may be eligible for a Gap Exception with the provider you saw.

Sorry this has happened to you and that you weren't notified. If you have the ability to check your benefits and provider status online it's best to always check this before going in to your appointments to ensure you're getting the level of coverage you're expecting.

 

[Kitty 34]

Did you have to give your insurance info when you went for your mammogram? I do. If you did give them your info, I think they should have told you at that point (don't know if they legally have to, but it would have been helpful!)

I also don't believe the billing people at the doctor's office didn't know they have been out of network since January. How could they not know? They do the billing!

I thought the same thing when I handed my insurance card at the hospital for my mamogram. I would have thought they would have told me??

The lady at our doctor's billing told me she found out when people started calling (similar to my call) early July. She said she contacted PHP and that PHP said that our office needed to renegotiate to get PHP. She said that's why they didn't contact us patients because they are now renegotiating which could take 6 months according to PHP.

 

[WDWorBUST]

I'm so sorry this happened to you.

Although it sucks it is your responsibility as the consumer to know if your provider is in network. I feel like the providers have an ethical obligation to tell you, however that's just my personal opinion and for whatever reason the providers don't seem to agree with me. Actually they have so many types of insurance to keep up with I'm sure it's difficult for them too.

For future reference, I always tell employees to ask if the provider is in-network when them make an appointment (every time) and then again when they arrive to receive services. I know it seems like overkill, but it can potentially save you from this type of headache and expense.

Oh and make sure you ask if they are still "In-network" not if they accept it. They accept a lot on insurance that they are not an in-network provider for, but they will file claims....this is another one that I personally think the provider should know what you are trying to find out and yet have had employees end up using an out of network provider because they asked the question wrong.

 

[Kitty 34]

When is your open enrollment period for benefits and did your plan change with the last one--not the company the PLAN itself?

Last October. We always go over it very carefully. Nothing was on there about our medical services becoming "out of network" in January.

What's weird is I went to my doctor's back in January; got a prescription on my blood pressure, etc and never had an issue with that bill.

 

[kidzmom3]

the only time a hospital would know if you were in or out of network is if you need to pre-certified. During the authorization process they would know you were out of network and find out your portion to pay. They would contact you and let you know you need to pay that fee before service is rendered. Things that do not demand a pre cert and they would never know. (lab, routine xrays, mamograms, ER visits) There are literally hundreds of plans, plan types, networks.

 

[msmayor]

In today's world of health insurance, its up to the patient to know whether their providers are in-network or participating physicians. Doctors simply cannot be held responsible for informing their patients; there are far too many types of insurance and patients often change policies without the office knowing until they come in for a visit. In fact, many offices are never completely sure if you will be covered for a procedure...two different patients can have the same insurance but different levels of coverage. Doctors have no way of knowing how much coverage a patient has until submitting the claim.

 

[Chesire]

I think something is not right.
A few years ago I had an insurance (not private, but through the large company my husband works for) that reset everyone's deductible in November (with no notice) and stopped paying doctors their contracted amount. Within a few weeks, no offices were taking the insurance (there was no notice from insurance companies, they just stopped paying). Now, several years later, there is a class action lawsuit against them.
I would try taking to someone higher up at your insurance company and find out whats going on.

 

[Kitty 34]

the only time a hospital would know if you were in or out of network is if you need to pre-certified. During the authorization process they would know you were out of network and find out your portion to pay. They would contact you and let you know you need to pay that fee before service is rendered. Things that do not demand a pre cert and they would never know. (lab, routine xrays, mamograms, ER visits) There are literally hundreds of plans, plan types, networks.

Thanks for the info. Saves me a phone call to the hospital on this.

In today's world of health insurance, its up to the patient to know whether their providers are in-network or participating physicians. Doctors simply cannot be held responsible for informing their patients; there are far too many types of insurance and patients often change policies without the office knowing until they come in for a visit. In fact, many offices are never completely sure if you will be covered for a procedure...two different patients can have the same insurance but different levels of coverage. Doctors have no way of knowing how much coverage a patient has until submitting the claim.

I agree. That's why I was surprised when PHP told us our doctors' should have notified us!!

I think something is not right.
A few years ago I had an insurance (not private, but through the large company my husband works for) that reset everyone's deductible in November (with no notice) and stopped paying doctors their contracted amount. Within a few weeks, no offices were taking the insurance (there was no notice from insurance companies, they just stopped paying). Now, several years later, there is a class action lawsuit against them.
I would try taking to someone higher up at your insurance company and find out whats going on.

A lady called my yesterday from the headquarters (in Wisconsin) of the company my DH works for here in mid-Michigan. She is quite interested in this case. Wasn't sure if I was going to start calling this a case yet!!