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Medical Bill From Day-Surgery Center Whose Contract With Our Insurance Had Expired at Time of Service.
Our PPO insurance has extremely high annual deductible & relatively high co-pay (we are seniors, my spouse is self-employed – it’s the only way we can afford any insurance at all).
My spouse had colonoscopy done late last year. Our insurance sent authorization to the gastroenterologist doctor who was to perform procedure. This doctor scheduled procedure at a day-surgery center. Insurance did not issue pre-authorization for this surgery center – only to the doctor.
On the date of service (DOS) – our credit card was charged $2000 as a pre-payment.
When the bill from the day surgery arrived – it was for $6800 less the $2000 we prepaid = $4800. This is apart & separate from the co-pay charges by the gastroenterologist & the anesthesiologist.
Based on the Explanation of Benefits (EOB) from our insurance provider (in Feb 2008) – disallowed charges was over $2300, and allowed charges was only $2865 – all of which was chargeable to us. The insurance wasn’t going to pay anything – the burden is all on us (don’t ask why).
Here’s the problem:
I found out from our insurance that at the time of service – this surgery center’s contract w/ insurance company had expired. IOW, they were NOT contracted with our insurance when they took my spouse as a patient – and they did NOT REVEAL this info to us. How would we know that? The gastroenterologist may or may not have known it either that the surgery center’s contract with the insurance had expired. If he did, why would he send us to that facility?
Therefore, this surgery center’s invoice stands at $4800 (which is $6800 less pre-payment of $2000).
I had asked for help from both our insurance customer service dept. & insurance broker – and they both said that the surgery center could not, by law, have turned us away even though our insurance wasn’t contracted with them on day of service. But why would they have scheduled us in the first place – if they knew that their contract has EXPIRED, was under re-negotiation at that time, and they had NO firm contract with our insurance?
I know I should have talked to the surgery center and tried to negotiate the amount down – as low as possible.
I have been in touch with them 2 – 3x in March – April 2008 (to coordinate the $2000 payment we made which did not show in their first invoice). But I have not been in touch since then – I am very upset, and at the same time I get very very anxious (just thinking about calling them) because I don’t know how to approach this situation such that I could show them that they seem to have acted with malicious intent & possibly even fraud. I want to put them on the defensive – instead of us being on the defensive.
Has anyone experienced something similar – and what did you do? I urgently need rational & intelligent advice. I am afraid they might have referred us to a collection agency already – there is an unidentified computerized message on our phone asking us to call a certain number – without identifying who they are..
HELP!!! Thank you so much in advance.
What a difficult situation in which to find yourself.
The doctor would not know if your contract covers a particular center. The best bet is always a call to the carrier to verify the status of the facility. I am surprised, however, that when you presented your insurance information to the surgery center that they did not inform you at that time that there was no current contract.
I have a few questions/thoughts:
1. Is there a stipulation in the insurance contract that they do not pay ANY out of network fees ? ( Some PPO’s have out-of-network rates. My carrier always pays a percentage but it is higher than if in-network.) This would not relieve the entire burden but it could minimize it.
2. If the surgery center did re-negotiate a contract with the insurance carrier that took effect after your date of service, ask if the insurance carrier will pay out based on the fee schedule in place now.
3. Ask for a written copy of the surgery center’s payment policy and any Patient/Consumer Bill of Rights they may have issued. You can also check to see if they have a mission statement or an organizational values statement. You may find an avenue of redress in any of those. If they have violated their own stated policies, they are often quicker to reach accommodation with you.
4. See if your County or State has a health care ombudsman or Insurance Commissioner who can advocate for you.
5. Appeal to the Community Outreach or Consumer reporter at a local media outlet to see if they will intervene.
I wish I could offer something more substantive than my best wishes for a speedy, equitable resolution.