Can your health insurance cover a hospital without covering the attending physician the hospital assigned?

Question

I n April I was taken to the hospital via ambulance having multiple seizures. I went to a hospital that my insurance considers in-network, but then they said that my attending physician (whom I was assigned not that I chose) was not considered in-network and was only partially covered . I spent about 5 days in the hospital. We are being charged nearly $1200 just for the physician that we did not know was out-of network. Can the insurance company do this? Is it standard policy with all health insurance?

Answer 1

The short answer is: yes, they can, and they do.

Hospitals, doctors that have hospital privileges, and the labs in the hospital are all considered separate entities and bill separately. Not all of them participate in every health insurance plan.

Now, in your case, you have grounds to appeal. Since you were admitted to the hospital on an emergent basis and not via your own personal physician, therefore having no say in which doctors treated you, I suggest you first call the the provider that is billing you and let them know you're going to appeal it with your insurance company and that you will keep them informed, and ask if you can count on them to help if you need it. (They will probably agree - they want to get paid, and they generally don't care by whom.) Then call member services at your health insurance company and explain the circumstances of your hospitalization and ask them to reconsider the claim, if they can not, ask them how you can appeal it - including the contact name and address and a phone number if it can not be accessed by member services. You might have to jump thru some hoops for this - insurance companies count on that - but if you're persistant, you should win. (Enlist the help of your regular physician too! They can often provide documentation of medical necessity.)

Good luck!

Answer 2

I am sorry to say but yes your insurance company can do this. If you were treated at a in network hospital most insurance companies will have something in your plan that is referred to as a PEAR benefit. This means that if you are treated at a participating hospital all pathologist, emergency room physician, anesthesiologist and radiologist will pay as in network as long as the hospital is in network. However if your provider does not fall under these categories it may remain as out of network. If this provider charged for "hospital visits" while you were in the hospital then it would not be considered under the pear benefit. However if it was the ER physician than they should honor this charge as in network. I would definitely recommend calling your insurance company and finding out why it is not being paid and find out how you can appeal the charge. It will be worth your time to send in a letter of appeal explaining that this was an emergency situation (or even life threatening) and you had no choice. Also, you may want to find out if your plan is self funded. If it is then it is the employer that makes the final determinaton and there is a possibility that they will make an exception and allow this as in network due to the circumstances. Good luck!

Answer 3

MOST of the time, they will consider any attending physician at the hospital (staff physician) as an in-network provider, if the hospital was in-network.

Did you ASK them, how is it that only the HOSPITAL is in network, and the STAFF is not? I'd appeal this decision. Start with a phone call, and then do it in writing.

Answer 4

Unfortunately, that is the way it works. You can try to go back to the hospital and see if they will write-off some of the physician's charges for you but it has a high probability of not working. It works in some cases.

It seems evil but that is how it works. Somehow they want you to have all of your care providers approved before you use them - concious or not. Most of the time the ambulance service is not covered. You may want to keep your eyes open for that bill.

Answer 5

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