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Can Ins Co Pay for Doctor Not in Their Network, Then Not Pay Hosp. Bill?
jdeekdee asked:
HMO ins. co told me I could take my child to PCP (primary care physician) that is not in their network (none in our area). Ins. co said we just pay $10.00 above co-pay.
We went to this doctor many times, ins. paid this dr. each time. We paid the $10.00 each time. This dr. referred my child to go to hospital.
Now ins. is not wanting to pay for this hospital bill cause doctor who referred this is not in their network.
I talked to ins. and they said they should have never paid these dr. bills and that is was their mistake, so I wouldn’t have to pay the hospital bill and that they will.
Now the ins. co is saying they don’t have record of that person telling me that.
And they said they never told me I could use out of network dr. so now they are not paying the hosp bill.
There is a person from ins.. co who is working with hospital. I called ins. co. to talk to this person. Ins. said there is no record of this person corresponding with the hosp..
HELP!!!
question to everyone here- isn’t the ins. co violating their own policy by telling me I CAN go to a dr. out of network, and then they paid for this dr?
Can’t I file an appeal or complaint because of this? It just don’t seem right that they can do this wrong, but then I still have to pay the hosp bill.
TO SCORPIO9, HOSP TOLD ME THAT INS DID PAY, DOES INS HAVE TO SEND ME DOCUMENTATION PROVING THEY DID PAY? I DON’T WANT TO TAKE THEIR WORD FOR IT….
medicare fraud
<BR%20/>Tags: Mistake, Primary Care, Doctor Who <BR%20/>HMO ins. co told me I could take my child to PCP (primary care physician) that is not in their network (none in our area). Ins. co said we just pay $10.00 above co-pay.
We went to this doctor many times, ins. paid this dr. each time. We paid the $10.00 each time. This dr. referred my child to go to hospital.
Now ins. is not wanting to pay for this hospital bill cause doctor who referred this is not in their network.
I talked to ins. and they said they should have never paid these dr. bills and that is was their mistake, so I wouldn’t have to pay the hospital bill and that they will.
Now the ins. co is saying they don’t have record of that person telling me that.
And they said they never told me I could use out of network dr. so now they are not paying the hosp bill.
There is a person from ins.. co who is working with hospital. I called ins. co. to talk to this person. Ins. said there is no record of this person corresponding with the hosp..
HELP!!!
question to everyone here- isn’t the ins. co violating their own policy by telling me I CAN go to a dr. out of network, and then they paid for this dr?
Can’t I file an appeal or complaint because of this? It just don’t seem right that they can do this wrong, but then I still have to pay the hosp bill.
TO SCORPIO9, HOSP TOLD ME THAT INS DID PAY, DOES INS HAVE TO SEND ME DOCUMENTATION PROVING THEY DID PAY? I DON’T WANT TO TAKE THEIR WORD FOR IT….
medicare fraud
yes they can unfortunately
you knew the MD was not in your network
and should have had a list of all participating hospitals and used one of them
sorry
you have to stop “calling” and start “writing” so that you have records.
The insurance company doesn’t have to pay because youre’ outside of their network, however, you need to analyze the entire hospital bill and see if any of the services are in network – perhaps the pharmacy, or the lab work, so you might be able to get them to pick up some of the bill.
Before a hospital visit, you always want to pre-submit to the insurance company for approval, in writing – even if in network, because there are still sometimes things that aren’t covered.
Hi, I’m the health care plan administrator at the company where I work. In other words, I’m the person at our company that the employees come to in order to find out anything about our health insurance benefits.
Unfortunately, the insurance company can refuse to pay bills from doctors or hospitals that are not in their “network”. The reason is that these doctors and hospitals have not contracted with the insurance company to charge lowered prices for their services.
Your best course of action at this point is to go to the hospital where you received services and talk to the insurance coordinator (they may go by another title). I’m a little surprised that they didn’t confirm insurance coverage before services were rendered, but it does happen. Go over all the charges with the hospital and ask them why the insurance company is refusing payment. Find out if they have any provision to lower the charges since you were expecting these to be covered by insurance and tell them that it was a complete surprise to you that you’d be responsible for the charges. If all else fails, they very probably have a payment plan to offer you.
Keep in mind that they routinely face total non-payment by many patients every year, and they may be weary of people who try to get out of paying and depending on the person’s patience they can be rather demanding. The best approach is to be pleasant, but inquisitive, and don’t give them the idea that you’re ready to skip out on your bill if they don’t find a way to work with you. The person will be much more likely to try to find a solution that fits you and them. If they sound too busy to talk to you at the time that you call, then ask when would be a good time for you to call back and discuss solutions. Best of luck.
08/31/06
Hi again,
I’ve read and re-read you’re question and the comment you put after it…I think you’re asking that if the insurance company agreed to pay the out of network doctor, shouldn’t they also pay the hospital bill, right?
Unfortunately it doesn’t work like that. Just as there are out-of-network doctors, there are also out-of-network hospitals, labs, and other facilities. Each place or person that you go to that’s out of network you risk incurring bills that won’t be covered by insurance. I had a surgery once where the doctor was in network, but the hospital was out of network and I had to pay the hospital bill, but I knew that up front because I checked on what all would be covered and what wouldn’t…..in fact, the hospital made me pay up front because they wanted to make sure that they got their money, since the insurance wouldn’t be paying them.
Best thing to always do is to check on every little bit of what you might get charged for. The main categories to check on are #1 the doctor, #2 the laboratory where tests might get done on bloodwork, etc (the doctor and/or the hospital will be able to tell you what labs they use, find out which are covered by your insurance and ask them to use one of those), #3 the hospital where you will be having a proceedure done (here again, you need to check with your insurance on what hospitals in your area are in-network), and #4 any anethesiologist or other doctor that may be needed for surgery or care.
Don’t depend on your doctor to check on everything, unless he/she explicitly tells you that their office will make sure that everything is covered by insurance before they do anything. Most of the time the doctors have their favorite labs and certain hospitals they use and work at, and they are too busy to bother with making sure that your insurance company will pay…..thus sticking you with an unexpected bill.
Also, one more thing. Just because a doctor refers your child to go to a hospital, doesn’t mean that the insurance company agrees with the decision. Especially since the doctor was an out of network doctor, everything that they may potentially decide can be overridden by the insurance company. The doctor is out of network for a reason…either he/she won’t work with the insurance company on their charges, or the insurance company deems that a doctor prescribes expensive medication or medical proceedures that are beyond the limitations that the insurance company is comfortable with paying for….etc.
I worked in health insurance for over 12 years now. What you need to do is write an appeal. The record of the phone call you made is probably purged, meaning only the appeals department can pull it up. Also you can argue why they have been paying the physician innetwork if they didn’t give you the approval to see him.
You should have gotten an approval letter before seeing this dr. In the future, do not make a move until you have an approval letter in hand.
The hospital bill most likely needed a pre-authorization. You have a chance of a positive appeal if you can first prove the insurance company gave you the go ahead to see that dr.
But, be aware that somewhere in your insurance policy it probably states that an authorization from the insurance plan is needed before making any inpatient or outpatient visits. If so, your fight might be harder than it should be.
Hi, Ive been working in managed care for over 20 years and first thing is I need to know what is the name of your health plan? (eg: Blue cross, Aetna). Every healthplan has in place a signed agreement with you, the member. Sure the doctors and hospitals have their own little contracts but ultimately you are signed up with the healthplan. And hidden somewhere within this membership agreement there is a clause for them to pay your medical bills. This is what is called “Gaurentee of Payment” They gaurentee your bills to be paid. you pay them premiums and they pay your bills. The way this works is this, the doctors offices and the hospital will need to bill and re-bill all these items to your medical group again and again for a total of at least 3 three complete billing cycles, (approx 90 days). Tell your doctors office and hospital billers that after the third denial of these billings they neeed to send all the bills along with proof of the three billing cycles with copies of denials to the health plan directly ( usually send it to the provider relations rep) and have them title the envelope “Gaurentee of Payment”. Then your healthplan will pay these billings and probably deduct thier costs from your medical groups monthly capitation amouont. So get all the bills together and make photocopies of them and explain all this to the hospitall and dr’s offices in question. Good luck