if insurance rejected claims from a hospital and the hospital sent bill to me, what should I do?

Question

my son had a operation in a hostpital in the insurance network. But some of the hospital claims were rejected by the insurance saying the providers are not in the network. The hospital is in the network, I don't understand why insurance says the provider is not. So, what will be my steps to resolve the issue? Certainly, I believe it should be the issue between the hospital and the insurance company.

Thanks,

Answer 1

Contact your insurance company. This is a very common problem the anethesiologist or pathologist were prob. not contracted with the insurance company. So explain to them that this is out of your control, and as long as the insurance company was notified of your procedure before the surgery it really shouldn't be a problem.

Answer 2

Well, it's not. The insurance company is the third party, paying on behalf of the hospital. But don't panic, this is actually usually pretty easy to resolve. Here's what you do:

1. With the claims rejection form in front of you, call the number on the back of your insurance card, and tell them that you have these rejection forms - if the procedures were done at an in network hospital, all the employees working at that hospital should be considered "in network". BE SURE TO WRITE DOWN THE NAME OF THE PERSON YOU TALK WITH, and the date and time of the call.

2. They "should" either say, oh, yes, we're resubmit the bill, this should be covered, OR give you a more clear explanation about why a procedure performed at an in network hospital is not considered in network. In either case, take notes. But I'd expect they'll resubmit, and send payment out.

3. Also, call the billing office at the hospital, tell them to note your file that the insurance company is reviewing the charges, and are expected to pay. That should buy you a little time.

Answer 3

Don't leave it up to the insurance company and the medical provider to sort things out. They will take months to years to resolve this problem. You need to be take the initiative to resolve this issue. If you have any supporting documents that the hospital is in the network, provide it to your health insurance. The person at the insurance company may have over looked that fact and send a form letter stating the claim is rejected. Provide them the provider's code number and make sure the insurance was in effect at the time the provider rendered their medical services to you. Contact the hospital and get them involved. Don't ignore their letters. Make them help you solve the problem. If a customer service is giving you a hard time, get a supervisor. As an incentive, tell them "look if you want to get paid, I need your assistance." Emphasize they will not get paid unless they make ssome effort. Make the hospital aware of this problem. That will slow down the process of sending you to a collections agency. If the insurance company change their provider network prior to your medical treatment services and did not notify you of this change, they should (not that they will) pay for your medical bills. If there is a co-payment, you should go ahead and payment. It shows good faith in attempt to paid the bill in full. Be sure you make both the insurance company and the medical provider aware of this problem. Follow up with the them and get the hospital involved to put more pressure on the insurance company for payment. Good luck.

Answer 4

It's very common for doctors to have privileges in multiple hospitals, and for a hospital to be in your insurance network but a doctor who might have priveleges there not to be in network.

I'd contact the insurance company or check your contract to see if ANY benefits are paid for out-of-network providers - sometimes partial payment is given, usually with a higher deductible.

If not, you're likely legally responsible for the additional sums. I know this isn't what you wanted to hear. Many people aren't aware of this possible situation, and don't check ahead of time to see if everyone who will be involved is covered by their insurance.

Usually the doctors bill separately from the hospital bill. You say "some of the hospital claims were rejected" - were those bills that actually came from the hospital, or from somewhere else like from a doctor's practice? If the bills were directly from the hospital, you might have an arguing point. If they came from a doctor who is not in network, then you're likely responsible for the payment.


Good luck.

Answer 5

The hospital may indeed be in network but the physicians have to have a contract with the insurance as well in order to get paid. What type of insurance do you have. Try calling the insurance to get help or try calling the Dr.'s office that was out of network and work something out with them. Unfortunately its up to the patient to make sure services and doctors are covered under your plan. You are ultimately liable for the bill. Good luck. If you need more help on this or some insight send me a message

Answer 6

Find out from the insurance company on 'How they inform the policyholders if there are changes in the hospitals network'.

If you are not satisfied with the reason given to you, find out your 'Consumer Rights' and negotiate with the insurance company. If this way cannot solve your problem, then you can seek help from the Related Goverment Organisation which is handling dispute between consumer and healh insurance claim.

Answer 7

I would call the insurance company to see what providers are in network for the hosipital, and then check with the hospital to see why they weren't used. It may be the hospital's fault for not chosing the right doc per your insurance coverage.

Answer 8

You will need to demand that the insurance company show how they are not responsible for these claims.

You may find the insurance company will require you to pay them and then be reimbursed later. Not every department in a hospital is owned by the hospital so they may not take payments from your insurance company.

If you are not satisfied with the answers you get a letter to your state insurance board will be the next step (explain what happened and what you have done to try to resolve it.) You will need to include copies of all bills (paid or not) and copies of all letters you send to the insurance company.

If that doesn't get you anywhere (about a 50/50 chance it will) you will need to see a weasel, (Umm lawyer) for breach of contract.

Answer 9

1) Notify your insurance company that the hospital sent you a bill.

2) Use the bill as toilet paper.

Answer 10

ignore telephone calls. you could desire to assemble up the place of work work and pass communicate to the wellbeing center's billing supervisor IN guy or woman. stick to up with an authorized letter asked that it superb the defective coverage declare. Be a nag until the wellbeing center submits the corrected declare - purely squeaky wheels get greased.