Can an insurance company legally do this?

[suzannen]

A few years back, when our office staff had a number of unexpected rejected claims, our HR department learned over the phone that an entire hospital network was suddenly no longer in-network. This hospital is one of the largest and most prestigious in the NY metropolitan area, with thousands of doctors and labs involved. It affected every person in our office and no one was given notice by doctors, the hospital or the insurance company and had no recourse what-so-ever. ALL of my doctors worked out of that hospital. The insurance company said they had been unable to reach a satisfactory plan with the hospital administrators. It took two years of negotiating before the hospital and all of its doctors went back in-network. For those of us who didn't want to start switching all of our doctors, it cost us a lot of out-of-pocket money during that time.

Now I always call the day before my appointments to make sure they are still accepting my insurance plan, so at least there are no surprises.

 

[mhsjax]

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!!

These contracts renew pretty much every January, if the Dr didn't notify you, it sounds like the Dr dropped the ball also. I did Insurance filing for years and trust me, they know if they are participating or have not renewed each year.

 

[bgirldeb]

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.

Some Dr's offices may be more proactive and call to verify benefits, but I agree, the patient can do this themselves.

A few years back, when our office staff had a number of unexpected rejected claims, our HR department learned over the phone that an entire hospital network was suddenly no longer in-network. This hospital is one of the largest and most prestigious in the NY metropolitan area, with thousands of doctors and labs involved. It affected every person in our office and no one was given notice by doctors, the hospital or the insurance company and had no recourse what-so-ever. ALL of my doctors worked out of that hospital. The insurance company said they had been unable to reach a satisfactory plan with the hospital administrators. It took two years of negotiating before the hospital and all of its doctors went back in-network. For those of us who didn't want to start switching all of our doctors, it cost us a lot of out-of-pocket money during that time.

Now I always call the day before my appointments to make sure they are still accepting my insurance plan, so at least there are no surprises.

I would go one step further and call your insurance company directly to make sure the provider is participating on their plan. I had a time where a walk in clinic said they "accepted" my insurance, but then I learned it was out of network after the claim was processed. The sad thing is that I worked in customer service for another health insurance company verifying benefits and claims at the time and should had known better

 

[minniecarousel]

I imagine that your State's Insurance Commision would want to hear about this.

It's rather unfair that you go for a yearly, routine exam, only to find out (after the fact) that it is not covered at the facility you've always had it done.

In the past, we've been sent letters warning us that the insurance that we have might be unable to satisfactorily negotiate with the hospital group we use. It may be a California State Law that they must notify us of even potential problems.

 

[suzannen]

Some Dr's offices may be more proactive and call to verify benefits, but I agree, the patient can do this themselves.



I would go one step further and call your insurance company directly to make sure the provider is participating on their plan. I had a time where a walk in clinic said they "accepted" my insurance, but then I learned it was out of network after the claim was processed. The sad thing is that I worked in customer service for another health insurance company verifying benefits and claims at the time and should had known better

Actually, I go on-line and print out the page from their website with the physician's name, address and phone number on it, showing the doctor is currently listed, that way I have the date printed out on the sheet to try to cover all bases. That's come in very handy during a few insurance arguments. I had dated proof of the info the insurance was putting out there and ended up receiving the money for several claims they had been trying to deny.

 

[msmayor]

Some Dr's offices may be more proactive and call to verify benefits, but I agree, the patient can do this themselves.

I think patients should consider this the rare exception rather than the norm, though. There simply isn't enough time in the day to do this for all patients.

Its not the provider's responsibility to find out if an appointment/test/procedure is covered. Its always the one responsible for paying the bill to determine that...the patient.

 

[golfgal]

Actually, I go on-line and print out the page from their website with the physician's name, address and phone number on it, showing the doctor is currently listed, that way I have the date printed out on the sheet to try to cover all bases. That's come in very handy during a few insurance arguments. I had dated proof of the info the insurance was putting out there and ended up receiving the money for several claims they had been trying to deny.

Our insurance company has a disclaimer that this list may not be up to date and that you should check with your dr or call the insurance company.

OP, any chance that when they reregistered you some box didn't get checked? We had one of our kids "fall off" our insurance because they forgot to add him during some computer transfer or something. It might be as simple as a clerical error too. Did you check with HR at the company to see if THEY changed something since they are the ones that pick your coverage, NOT the insurance company.

 

[mjkacmom]

I imagine that your State's Insurance Commision would want to hear about this.

It's rather unfair that you go for a yearly, routine exam, only to find out (after the fact) that it is not covered at the facility you've always had it done.

In the past, we've been sent letters warning us that the insurance that we have might be unable to satisfactorily negotiate with the hospital group we use. It may be a California State Law that they must notify us of even potential problems.

I've never had a whole hospital group drop my insurance, but I've had many providers drop my insurance, and I was never informed. I always check the website before I make an appointment, because about 1/4 of the time, I find my doctor is no longer on the list (and I have Aetna).

 

[Kitty 34]

Our insurance company has a disclaimer that this list may not be up to date and that you should check with your dr or call the insurance company.

OP, any chance that when they reregistered you some box didn't get checked? We had one of our kids "fall off" our insurance because they forgot to add him during some computer transfer or something. It might be as simple as a clerical error too. Did you check with HR at the company to see if THEY changed something since they are the ones that pick your coverage, NOT the insurance company.

The lady at HQ of DH's company had no clue that the insurance company had decided to call our area out of network. PHP had told us that we were to notify DH's company and ask if they had chosen to keep the "out of network" insurance group. HQ didn't even know what I was talking about when I told her that.

Like many of you are stating......I've learned. From now on I will always call ahead of time on any Dr. visits and tests when of course I find a new doctor.

I guess, having gone to the same doctors with the same insurance for over 10 years I definitely had gotten too comfortable and trusting.

 

[mtemm]

we had a problem 9 years ago when I found out I was pg with my first. I was so excited!!!! I didn't like the hospital my current gyn was with, so I researched and found a great ob/gyn affiliated with where I wanted to deliver. I am a very ducks-in-a-row person, so I made sure she was in our booklet (she was, and she was on their website as an in-network provider). I made the appt and verified with the office that she accepted our insurance. then I went a step further and called my insurance company to let them know I was pg, that I had my first appt, and who it was with. they verified she was in network and wished me well and gave me all sorts of great info about coverage for my pregnancy.

so all was great!

I go to my first appt. and my 2nd. and my 3rd. I have my screening tests, and my ultrasound, and an amnio (my screening tests came back with some concerns). I have my 4th appt. Then suddenly we start getting these HUGE bills. HUGE. saying she was out of network and we owe a lot of money we didn't have for all of these appointments.

WHAT????

I still had all my documentation from my initial phone call with the insurance agency. I still had all my info from every call, the booklet, etc, etc.

turns out I called on june 21st. on july 1, things changed, and they were no longer considered in network.

no one anywhere along the way had told me.

I was devastated and invested with my dr and my care at that point. I didn't want to change. my husband fought the good fight and they agreed to keep this dr in network for the rest of the pregnancy, but every single month we got billed as out of network, and he had to call and have it resolved once again. it got really crazy for a while, until he found some supervisor who seemed to have the ability to trace previous calls and such and understand what was going on with my case.

to top it off, their booklet that came out later that year still listed this dr as in network. she was still on the website for a good couple of years after, might still be for all I know (we have different insurance now). and yep, we pointed this out to the company so they could remove the info in case anyone else had problems. they never did do it.

so yes, it can and does happen.

I'm so sorry it happened to you. I hope you can find some resolution that works for you.

good luck!

 

[golfgal]

The lady at HQ of DH's company had no clue that the insurance company had decided to call our area out of network. PHP had told us that we were to notify DH's company and ask if they had chosen to keep the "out of network" insurance group. HQ didn't even know what I was talking about when I told her that.

Like many of you are stating......I've learned. From now on I will always call ahead of time on any Dr. visits and tests when of course I find a new doctor.

I guess, having gone to the same doctors with the same insurance for over 10 years I definitely had gotten too comfortable and trusting.

Since no one involved in the decision making process at the company, the dr's office or the insurance company seems to be aware of this, my guess is that it is a computer malfunction somewhere. Are you sure your PLAN did not change. Your plan can change but not the company and it may look the same but not be exactly the same. Did your co-pay change, did the name on your card change, did you get a change in your prescription coverage, anything like that? Companies generally shop plans around every year or two and while your coverage may be the same or very similar, the plan itself may have changed and thus the network changed.

One example may be something like going from Aware Gold to Aware Gold+. Call the HR department and ask if they changed plans with this new sign up period. The fact that this all changed in January leads me to believe that either YOU specifically got signed up for the wrong plan when they transferred the info over for the next plan year or your group got put into a different plan altogether either on purpose or not.

 

[LilyWDW]

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.

Hmmm... I wonder if the hospital even contacted your doc about the change. While it wouldn't make sense that billing didn't know, that could explain why the doc or the receptionist might not have known.