It's a first for me..PPO for ER, charged for Non PPO Dr..anyone else?

[sullins5]

..So we've had BCBS for 23 years, gone to the ER maybe three times total. In Dec, my dh had a 'spell' at work, I met him, called on the way to the ER to make sure it was one of my hospitals in network. Call was recorded and indeed it was. We got a $650 bill from the ER physician because HE was out of network. When I asked BCBS, they said it was my responsibility to ask at the hospital (in the ER, thinking dh had had a TIA) if the Dr was preferred.
OMGoodness! 25 calls later and I'm still wondering what's going to happen!!
BCBS said to call the hospital, and the hospital said to call BCBS...I have to laugh, because the scenario is ridiculous!
The hospital said it's "Ridiculous to ask the ER if a doc is preferred, of course they are...", BCBS said "People better start learning to ask"...

Lessons learned for the next ER visit...and food for thought!!!

Celebrating our 1st Disney Cruise Oct on the Magic!!!

 

[mickeyplanner08]

We had something similar....anesthesiologist who did epidural was not in network. Their practice has "chosen to not participate." Super, duper annoying!

So, I sort of feel your pain and I wish you luck!

 

[Mollie Mooster]

Unfortunately, yes it happened to me 3 times. For my daughter's surgery the facility and the surgeon were in network, but the anesthesiologist was not. Then same thing in an ER and another time went to have a growth removed and the doctor sent it to a lab that was no longer in the network. We did not find any of this out until the bills arrived.

 

[sullins5]

Don't you just love it? Funny thing is the hospital said "All our Drs are ppo..", after 25+ calls, the hospital ER billing dept., was very sympathetic and said it was BCBS responsibility since it was a "True Emergency" since we thought it could be a stroke (It was not...we are thankful!), and BCBS told me to appeal, but they didn't think it would do any good. Aren't they kind? My last phone call and/or call back the lady told me BCBS HAD to pay it..and then when I said "And what would you have me do with this physicians bill of over $600 when I get it?"
She said to send it to her!!! So I'm going to!

Hopefully, it'll be another 25 years before we go back to an ER, but I know now when I enter to make sure there's a ppo doc on board!

How sad that insurance has become so 'nitty gritty', and that there are tons of 'loop holes' to watch for! Hope our story helps the next disboarder who finds him/herself in an ER!!

Still Celebrating our 1st Disney Cruise in Oct '11!!!

 

[amy-momofthree]

We had something similar....anesthesiologist who did epidural was not in network. Their practice has "chosen to not participate." Super, duper annoying!

So, I sort of feel your pain and I wish you luck!

Same thing happened to me in May and yes, It's soooooo frustrating!

 

[amy-momofthree]

Yes, tons of loop holes!!

had a mole removed in September. It took ten minutes in the office to have it done, no big deal. My insurance won't cover any of it, $455,because it's considered "surgery" and I didn't pre-certify with the insurance.

 

[QVCshopper]

This has happened to me many times; once for my broken elbow and twice for my son's dislocated elbow. You have to call the place that billed you and also your insurance. There's a way for your insurance to code the bill so you don't have to pay it.

It's not your fault that you were seen by a doctor not in the PPO. It will probably take many calls, but hopefully you can get your insurance to cover it as I have three times now...

I should state that the person who finally told me how to code the bill was the place that sends out the doctor's bill. I then had to call my insurance and tell them how to run it through. This was through Aetna. Good luck!

 

[disfan07]

The same thing happens at our hospital. They actually tell you everytime and its in every piece of paperwork for billing that the hospital will charge you and you will get separate charges from the doctors, etc. AND that they dont guarantee that every doctor participates in teh same insurance plans as the hospital.

My hospital takes medicare, medi-cal, HMOs and PPOs (basically, everything) BUT, my GYN who is at this hospital does NOT take HMOs at all.

My surgery from June came to $350,000 total. Luckily, everyone was in-netowrk so it was covered 100%.

I have to say though, the ER is kind of weird. BUT, it depends on how the hospital employs their ER docs.

Our ER docs here are completely employed by the hospital itself so they have to accept every type of insurance that the hospital does. BUT, any specialists you might see are not necessarily the same way.

Some ERs though do employ their docs from outside Emergency physician practices that do not have to follow the same policies though.

 

[sullins5]

This has happened to me many times; once for my broken elbow and twice for my son's dislocated elbow. You have to call the place that billed you and also your insurance. There's a way for your insurance to code the bill so you don't have to pay it.

It's not your fault that you were seen by a doctor not in the PPO. It will probably take many calls, but hopefully you can get your insurance to cover it as I have three times now...

...Yep! I did it 25+ times..I figure someone will want to pay it or it'll drive them nutso calling so many times! lol...Actually, I've not heard back since the rep from the hospital told me to send them the Doctors bill, so I'm in that waiting phase.

Unfortunately, I do understand, if you have a 'minor' emergency asking who's in your network when you get to a PPO ER, but when you're thinking heart attack, stroke, or life on line emergencies, even the hospital staff said it was "Unreasonable to think you'd have to ask if the doc was ppo"...At least they were sympathetic...

The waiting begins!

 

[disfan07]

yes, hospitals are usually more understanding.

I swear, insurance compnies get enjoyment out of screwing with people. I think the big guys who create these policies enjoy it.

 

[StephMK]

Yes, we are still fighting w/BCBS over an ER bill for DS. He fell in a reststop bathroom with a wet floor & busted his chin. We spent 2 hrs in an ER away from home, with only about 20 minutes of those 2 hours being seen by a nurse or doc. His chin was numbed & he received 3 stitches.

We have been charged about $980 between the doc & ER. BCBS keeps saying the ER co-pay of $150 is separate from the co-ins/ded for the "surgery" & the doc bill is yet another separate charge, so nothing is apparently covered under the $150 co-pay. The first time DS got stitches, we were able to go to his regular primary doc & paid just the normal $20 office co-pay. BCBS did not charge us a separate "surgery" that time. Very frustrating.

 

[Firefly09]

All the more reason why I'm looking into health savings plans in place of the traditional health insurance.

 

[queenbetsey]

went through that with anthem blue cross. hubby had crushed the end of his index finger. er bandaged him up and said go to ortho. we did and the practice is in network. they did outpatient surgery and it was approved except for the anesthesiologist was not (seeing a trend here) I explained that most surgery centers tend to not be a byoa and frown on it when you do (no such thing right) not like we had a choice right. they covered only like 300 out of the 800 dollar bill. still going around with them. why on earth would they not have all the folks who work there on the same plans?

 

[bumbershoot]

Either the doc billed first or the doc's office billed with the wrong code. Call them, ask them to re-bill with the "emergency care" type of code.

Ask the insurance people to see who billed when. If the doc billed first, ask if they can make sure their system understands that this was an emergency situation. I dealt with a ambulance bill (in my city we pay for them, they aren't covered by taxes) for almost a year before an insurance CS person noticed that their system "thought" that the ambulance ride was for a non-emergent situation, and had paid out on that basis. Once she switched it around, I actually got a check back. (and then the ambulance company decided to honor the discount they initially said they would give me then took away a week later so I was done with them, too!)

I had a situation where I was told "emergency! emergency!" at an in-network hospital, by an MD that was on-call and just "given" to me, and it turned out he was out of network. He billed as non-emergent, and REFUSED to change it, and I don't know why. I paid for years on that thing, so de-moralized that I never tried harder. I ought to contact them again AND contact the insurance commissioner, because you can't just scream "emergency" and then not bill as such, especially when you KNOW you aren't a part of that hospital's network....


Good luck!

 

[sullins5]

Either the doc billed first or the doc's office billed with the wrong code. Call them, ask them to re-bill with the "emergency care" type of code.

Ask the insurance people to see who billed when. If the doc billed first, ask if they can make sure their system understands that this was an emergency situation. I dealt with a ambulance bill (in my city we pay for them, they aren't covered by taxes) for almost a year before an insurance CS person noticed that their system "thought" that the ambulance ride was for a non-emergent situation, and had paid out on that basis. Once she switched it around, I actually got a check back. (and then the ambulance company decided to honor the discount they initially said they would give me then took away a week later so I was done with them, too!)

I had a situation where I was told "emergency! emergency!" at an in-network hospital, by an MD that was on-call and just "given" to me, and it turned out he was out of network. He billed as non-emergent, and REFUSED to change it, and I don't know why. I paid for years on that thing, so de-moralized that I never tried harder. I ought to contact them again AND contact the insurance commissioner, because you can't just scream "emergency" and then not bill as such, especially when you KNOW you aren't a part of that hospital's network....


Good luck!

Thanks! Unfortunately billing got the coding from ER physicians group who thought all docs were ppo. And we never even saw this doc but a nurse practitioner, but this doc billed my insurance first. And he is a nonprovider. I've left this all between the hospital/doc/and my insurance, but boy have I been enlightened.
If it happens again, would I do anything differently? Well, since we thought this was a TIA, prob still go to the ER, but I would start the paperwork off and discussions off with making sure the doc was a ppo. I have learned alot from this. I have been kind to the hospital, to the billing, to BCBS because I know it's not the ppl that I talk too that have caused this, however, it would seem like there could be better ways to manage ppo's, hmo's, etc...so that you'd know what you're walking into!
Hopefully, putting this on here, the next time someone has an ER visit, they'll be a little more prepped than I was!

 

[disneychrista]

It is the same way at our local hospital. The hospital is in-network but the doctors are not.

 

[sullins5]

I will say, lest this sounds like a 'bitter apple'...that our ER experience was the BEST we have ever had! In fact, in one of my 25 calls, when I told the Insurance Representative at the hospital how pleased we were, she said "Well, now, this has certainly turned your visit sour huh?"...At least they understood the delimma.

Hopefully, because this really was an emergency, they'll waiver it at least somewhat, but if not, I have learned to be sure!

 

[bumbershoot]

Thanks! Unfortunately billing got the coding from ER physicians group who thought all docs were ppo. And we never even saw this doc but a nurse practitioner, but this doc billed my insurance first. And he is a nonprovider. I've left this all between the hospital/doc/and my insurance, but boy have I been enlightened.

So the doctor did bill first. OK then, call insurance. Make sure they see that it WAS an ER visit. Make sure their systems see that they were connected. Because you SHOULD have it in your insurance that in emergencies, you do not have to see an in network provider.

And then talk to the ER physicians group, since it sounds like you're saying that they are the ones who billed for him/the NP, and make sure that they have the "emergent care" code billed to the insurance company.

Probably the first thing you could do would be to call the insurance company and ask "in a true emergency, what would happen if we were assigned an out of network doctor? is there an exception to ppo/non ppo/in vs out of network coverage in an emergency?" If they say yes, go from there!


I have a good feeling about this for you, since it sounds like you hit *both* problems. We had Great West, which isn't a well known insurance company (I've rarely heard of it since, and never heard of it before), and they had that policy, to cover emergencies as in network. (all it would have taken for us would be for that ridiculous MD to bill it as he was calling it) And we were with Aetna's HSA plan for the ambulance ride ER visit, and they helped us with the "who billed first" problem. I think you'll prevail!

 

[sullins5]

Well, here's the deal...BCBS KNEW it was an emergency due to the fact I called 3 times on the way to the ER (and they have that documented). However, they stated when I called that it's MY responsibility when going to an ER to find out if the Drs were ppo or not. I told him that was ridiculous, and 'who does that when you're worried about someone's life?' and his response was, "Then I imagine you wouldn't really care if they were ppo or not, just to see a doc right?"
"And if you look in your manual, it does say that we are not responsible for nonppo's."
However, the hospital gave me more hope due to the fact that the woman told me to send her the doctors bill. And she's not over billing, she's not over Er, or the physicians, she's with the hospital's insurance program and happened to be one of the numbers I called. We will see...I can honestly say, lol, that I have never called 25 times about a health insurance problem, but this was the first.
My goal has been to NOT be ugly or disrespectful, but to plead with both sides that there really should be a happy medium, because why use a ppo if you're NOT going to get a ppo doc.
Thanks everyone for the input though! I'm going to keep all this handy, so when the bills keep rolling in, I can double check and see if I missed anything!

 

[Swimalie]

I had a similar situation. I was going to a fertility clinic that was in-network. They were drawing blood every 2 to 3 days and sending it to their clinic lab that they knew was out-of-network. I didn't know until weeks later and I started getting the EOBs for $60 per lab run. Total was $660! They could have sent the lab work to the in-network lab of theirs but they chose not to but didn't give me the choice. I fought it with the insurance and realized that they paid what they were supposed to. Eventually I wrote the CEO of he hospital and he wrote off all but the first lab run. So my bill went down to $60. After that, the clinic put a sign up stating the labs might be sent to an out-of-network lab.

So, write to the hospital and they might write off some of the expenses for you. In a time of emergency, you aren't always thinking about the cost.