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

[Donnainnj]

About the anesthesiologists. I was told none of the ones at our hospital are in network. Lovely.
Donna

 

[swilshire]

Same thing happened when DS broke his finger. Very annoying, but I wound up paying it.

Sheila

 

[scoochie75]

Happened to us. We were on vacation and our 2 year old got bit by a dog. We called the insurance company who told us which hospital we needed to go to for coverage. A few weeks later we received a bill from the doctor that saw her in the ER. Spent quite a few weeks fighting with the insurance company and Doctors billing dept - but in the end we did not have to pay it b/c the insurance company sent us and nothing was posted in the ER about DRs not being in-network for insurance plans that the hospital was in-network with!

 

[Styx Fan]

We had an insurance situation with my mom way back in 1986.

Mom was in the hospital and had been diag with terminal cancer. She needed a catheter in chest to administer meds and draw blood. It was a bedside procedure, but was to be done by a surgeon. Don't ask me what made me think of it, but I ask before the procedure if the assigned surgeon was part of my parents plan. (I was only 23 and didn't have really any insurance experience). Of course he wasn't. We were very surprised considering they had BCBS through GM and this was a GM town. As this was not an emergency situation, why wouldn't they verify this coverage?

It was very simple to get a participating doc. Turned out the one we got was a wonderful and well respected surgeon at the hospital!

We sure learned a lesson from that and saved several hundred dollars.

Glad OP brought this up, I had forgotten about this and have not been verifying this coverage in recent years.

 

[j's m]

Happened to me when DS was born. Hospital, ob/gyn and anesthesiologist were all in network. What no one told me was that a neonatolgist nurse was required to see all babies at birth and none of them were in network.

 

[Disney Ella]

Can you even ask to see someone who participates in your plan when you go to the ER? I just picture them laughing at you and telling you that when you come to the ER you see whoever's available next and that they don't have time to match up patients with doctors who accept their insurance.

 

[sullins5]

Can you even ask to see someone who participates in your plan when you go to the ER? I just picture them laughing at you and telling you that when you come to the ER you see whoever's available next and that they don't have time to match up patients with doctors who accept their insurance.

THAT'S the sad part. When I asked BCBS "What am I supposed to do, YOU sent me to this ER, and said they were preferred!" But he still said "It's your responsibility", I then told him, " You know, I'm not mad at you, it's just isn't this like a spiders web? Y'all pull us in, then as it gets deeper and deeper, we have no say...a little deceiving and manipulative". And what was sad was that he said "Yes maam, I do understand and you can appeal, but we don't have to cover nonppo's." It is stated.
And when I said that to the ER billing, physicians network, insurance at the hospital ALL of them said "It's unrealistic to think you'd walk in in a dire emergency and think to ask for a PPO doctor"...so they were all in total agreement.
I understand WHY insurance is so high, but I do think the industry could use some changes...This Mississippi gal has learned alot!

 

[tigger813]

Had a similar issue with a new Dr. at the practice. He was the only available Dr. when I went in and because the practice accepts he should've been included. They finally paid it and said they would do it this one time. I said well, your system needs to catch up!

 

[PrincessSuzanne]

This is not an uncommon practice. I work in a hospital and the group of ER docs may not participate, so there is always that chance. And, it may be that , as in our hospital, all the docs are from the same "group", that none participate in-netowrk, but there is supposed to be a clause or waiver with your insurance company to get around that and the insurance company should be the one to handle it.

I had this happen, as I say I work in a hospital, as a contractor, but my insurance has this hospital as a provider. I had to have an x-ray, and the radiologist that read it isn't in-network, well that isn't up to me to keep up with, because likely none of them in the group is and even so, they wouldn't hold my x-ray to be read by someone else if they were. Well, I wasn't aware of this until I got my EOB and a bill that didn't match up, so I called the Ragiology group and spoke to a really nasty rep that didn't know what she was doing. I called the insurance company and the really nice rep there said they were supposed to file it with the waiver (becuase the primary service provider, the hospital, is in-network, that makes the service in-network) and she took care of it for me.

As large a company as BCBS, you would think one of their reps would have had the right information.


Suzanne

 

[bumbershoot]

This is not an uncommon practice. I work in a hospital and the group of ER docs may not participate, so there is always that chance. And, it may be that , as in our hospital, all the docs are from the same "group", that none participate in-netowrk, but there is supposed to be a clause or waiver with your insurance company to get around that and the insurance company should be the one to handle it.

Exactly.


I would call back!


It doesn't matter that the *people* knew it was an emergency. It's the computers that need to know, if they have a clause about emergencies.

If this works out to be right, if the rep you spoke with at BCBS is saying the truth for their company, I won't be going with BCBS should it come up in the future. That's just nasty of them.

 

[3boymthr]

See here....

http://www.fchp.org/news/health-care-reform/~/media/Grandfathered-plans.ashx

In particular item 2 on page 3.

Then determine if your plan is grandfathered or not. If it is grandfathered, then I'm sorry. If it is not grandfathered and it has renewed since September 23, 2010 then they have to cover your OON ER visit.

It's funny to see this posting because we actually were just discussing this at work yesterday with regard to a couple of our plans and how some carriers are addressing NHCRA globally for varying benefits, whether the plans were grandfathered or not.

 

[lizbaby007]

This happened to my mom last year. She has BCBS shield as well.

She had went in to see her DR about her shoulder. He wanted an MRI done and sent her down the street. She called and then re-verified once she got there that they were in fact in network.

A month or so later she received a $200 bill. The place WAS in network, but the radiologist who read the MRI WAS NOT!! She never even thought to ask about that.

She was pretty furious and spent many hours on the phone with many people whom all agree that it was pretty darn shady! She ended up negotiating the bill with the rad's office and paid 1/2.

 

[riley2008]

Wow! I am so surprised by this! (Not sure why I should be though.) Same thing happened when my boys were born, but with a totally different ending.

My boys were born 6 weeks early and stayed in the hospital for two weeks. The hospital was in network as well as their pediatrician and my doc. I think that was it. (Labs, eqipment rental places for the neonate equipment, the opthalmologists, radiologists, neonatologists, cardiologists, anesthesiologists.... none of them were in network.)

Each time I got an EOB or a bill from one of these people/places, I called BCBS and told them that it was an "emergency", was in an "in-network hospital" and "had no choice of providers". Every time they paid at in-network rates then. (It was LOTS of calls, but never a problem with BCBS.) I only had the anesthesiologist not accept the rate of the in-network payment and they wanted their additional $50.00 or so. I thought that was pretty good.

Good luck and keep trying! (I recently posted about an issue with vision insurance - we were 1 day early for our "annual" eye exams. Most people said I was out of luck. I wrote my letter, apologized and asked for reconsideration. I sent my letter on Monday and already received one check! So I'm guessing they approved my boys too.) My point - keep trying - every situation is different.

 

[sullins5]

Ok...here's what I do know...No, we are not 'grandfathered'...we are BCBS fed program...Here's what I'm hoping, that the final number I talked to (number 25) asked me to fax her my denial from BCBS, I did so, and she said she would handle it. So, I am waiting...and waiting. IF I get a follow up doctor bill, I will send it to another woman with this hospital's own insurance program only because she told me too. BCBS said I could write an appeal, but I don't want too many irons in the fire. I do have the address and who to contact, but like I said before, I've tried to be very congenial, but also clear on what I thought would/should happen.
And just so all of you know, I was so pleased with our ER visit, they put my dh up to 2nd when they thought it might be a stroke, they took care of us (ekg, cat scan, etc ) and got the results all within 2 hours!! The ER, nurses and nurse practitioner did an AWESOME job! It's just a shame that all the 'nitty gritty' stuff popped up!
We shall see...
Hopefully, we'll all learn how to NOT be in these situations. Wish I could write a simplistic formula for the insurance agency so that they would understand PPO means PPO!


Celebrating our 1st Disney Cruise in Oct '11

 

[Jewel1310]

If you don't get satisfaction - always write an appeal. An appeal is the opportunity to review all the facts. Appeals are time limited so you don't want to wait too long as once it is beyond the time limit the opportunity is lost (time limit is often determined by the state)

As a pp noted it doesn't matter what notes say when a medical claim processes at an insurance company - what matters is what the computer says. More than half of all claims process with no person touching them. They pay or deny and apply cost sharing based on the benefit set up in the computer.

In your appeal note that you called the plan on the way to the ER, that you went to the facility they advised, that you didn't have a choice on doctors in this event, and that based on the fact that it was an emergency you would ask that this be covered at in network cost sharing. Don't wait - if the other person gets it straightened out before the appeal processes you can call the insurance company and withdraw the appeal. If the appeal is denied there is a 2nd level or a way to go to the state insurance department.

Good luck - usually, when you follow protocol like you did, these things can be worked out.

 

[sullins5]

Thanks....writing appeal today!