we have blue cross blue shield, my husbands surgery center was not part of the plan. We owe alot now what?

Question

all mds. at the center are in the plan. We never thought to check the center itself. Now we may owe alot.do we need a lawyer? It's lakeshore surgery center in chgo,il. Way wouldn't that be in the plan when all the md's are?

Answer 1

No, you need to call BC/BS first. Ask the doctor, WHY the surgery took place at that center. Most of the time, there's a good reason - like, that's the primary hospital he operates out of. Then you can tell BC/BS that, and get them to honor the charges. You can also appeal any denials you might get. I'd work at getting BC to pay before hiring a lawyer!!

Also, 9 times out of 10, the doctors "preapprove" the procedures with the insurance company - if this got preapproved, even if it was preapproved in error, you need to hold their feet to the fire to pay this.

Answer 2

When a provider (either a hospital or doctor) choses not to belong to a network (especially one as large as BCBS) there is a reason. Usually it has something to do with the amount of money the insurance company will offer for reimbursement for the procedures.

For example, the hospital may bill $20,000 for a surgery, but accept $10,000 as payment from for the procedure. That's called the negotiated rate. Depending on your plan, you may pay 20% and the plan pay 80%. Your contribution could be $2,000 (again, your particular plan will determine if a deductible and out of pocket maximum come into play).

The biggest surprise is when the insurance company claims the charge is "above reasonable and customary". They're basically saying the provider is over charging and they're only going to pay on a certain amount. In the example above, if the insurance company determines $12,000 is reasonable and customary, then they'll pay their reimbursement based on the $12,000 charge (and you as the customer are responsible for the $8,000 which is above reasonable and customary).

If the hospital is to survive, it must accept someone's insurance, so you need to find out what amount of money it will accept as payment. We know in my example the $20,000 is too high and the $10,000 is too low. Maybe the hospital needs $12,000. You need to negotiate with the hospital to accept that amount. It is very hard to determine the amount since it is confidential hospitals do not willingly let you know that amount.

Depending on your plan, there is usually a penalty for going out of network. It could be a higher deductible (one plan I worked with hada $10,000 deductible if you went out of network), or it would be a lower reimbursement (my current employer only reimburses 50% out of network).

I would not hire a lawyer right off the bat. First of all you need to know who governs your policy. As an employer provided benefit, the plan can be self insured (which means your employer will actually pay the claims thru an insurance company acting as an administrator). Most large companies will use this type of insurance product. Self insured plans are governed under ERISA and are overseen by the Dept of Labor. Smaller employers or employers looking for local insurance will normally buy fully insured products (HMOs, Kaiser, etc.). These plans are off the shelf and the employer has no discretion on how the claims are paid. In cases like that you need to work with the State Dept of insurance.

If this is an employer's insurance, contact the benefit department and see if they can help. Sometimes, it's a simple as the claim being misprocessed and someone from corporate can have it looked at a second time (with different eyes) and fix the problem.

Someone also mentioned the need for preapproval of a procedure. Most hospitals would normally check your insurance (since they want to get paid). I might go back to the hospital and ask why they didn't notify you that they were not in the network.

Answer 3

Not to be rude, but you said it yourself: you never thought to check the surgery center itself. Anytime a hospital procedure is done, you get a separate bill for everything - from the labs to any doctor who walks into the room, and the facility itself. And, no they don't have to be in-network with your plan.

Technically, it is YOUR responsibilty to check that all parts of the surgery are covered - that's part of your contract with your insurance plan. A lawyer isn't going to change that, since you kind of violated your contract with your insurance company. (Check your coverage packet if you don't believe me.) HOWEVER, you can appeal to your insurance company to cover the surgery center as an in-network facility. Be warned, it's not going to be a walk in the park - insurance companies count on that. It's going to be a drawn-out, frustrating process. Start with finding out the insurance's patient appeals process - with the proper addresses and contact department. Then see if the doctor who performed the surgery has privledges elsewhere - you can check on your insurance company's website to see all the hospitals they go to. If that's the only place the doctors go to, you didn't have a choice on where to have the surgery done. If the doctor goes to other facilities, find out if they were in your plan or not - if they are, then ask the doctor if he does this surgery at the other places - if not, make sure your insurance company knows that. If the doctor does this surgery at other places, find out why they used this specific place for this specific case. Is your husband a special case that needed a certain facilty - that makes a difference. If it was same-day surgery done at an outpatient-type faclity, mention this. You kind of have to break it down into dollars and cents for insurance companies. Same-day surgery centers are often less expensive than hospitals. Do this all in writing and keep copies. Follow up on it weekly - the doctors' offices aren't going to, it's your responsibilty to make sure this gets paid. And, if this appeal doesn't work, I'd suggest making a payment plan so it doesn't screw your credit.

Good luck!

Answer 4

The bill from the place the surgery was done is separate from the bill from the doc, so it's possible that the doc's bill would be covered but the center's wouldn't. A lot of docs go to multiple hospitals, but not all the hospitals the doc goes to are necessarily covered by your plan even though the doc is - I suppose the same would be true for surgery centers.

You might talk to the billing department at the center - they might reduce the bill if you can't pay it all.

Good luck.

Answer 5

Personally, in that situation, I'd hire a lawyer, especially one with experience in medical claims. A good lawyer can tell you up front about your options, can give you a good faith prediction as to whether you will be able to get BC/BS to pay, and can suggest a strategy to follow. The unfortunate truth is that insurers and/or hospital collection departments will jerk your attorney around less than they will jerk you around personally. Others here have given you great advice about trying to involve the doctors and trying to explore whether or not (and why not) pre-approvals were obtained, but I'd still recommend getting a lawyer "in the loop." Good luck.

Answer 6

I sympathize with you.I too have my insurance with them.Part of our responsibility in the agreement is to call the B.B.S.. to see if they will accept that facility.When this occurred to us we found they paid 80% of the surgery.Call them tell the rep. your circumstances.She can give you a better look at your prospects.However, some insight for you if you are unable to pay anything call the hospital then ask for a social worker.Not all but some hospital have what is called forgiven debt.It is always better not to accuse,not saying you are,but we can posture if we believe we were duped somehow.We as a society do not read or understand half of what we sign.

Answer 7

You should advice the an attorney, take your Evidence of Coverage with you. Or just call your health insurance company and find out if you have signed arbitration, if you have you cannot sue them - as you have already signed that away.