A hospital told me I was fully covered. Now doctor is giving me a bill. What should I do?

Question

No one told me the doctor was not on my plan, now I', being charged w/his hugh bill. What recorse do I have? It seems they accepted the $ already sent from my Insurance Co. but they are looking for more. I never go out of net work. I can't afford this bill nor do I believe the doctor should receive any further payment. I would have chosen an in net-work participan.
Any advice on how to tell his billing staff this so they leave me alone?

Answer 1

First of all, write an appeal to your insurance company. You don't really provide all the information regarding your hospitalization but it is worth a try. I had a procedure at an in-netwok hospital and got an anes. that was out of network (like I had a choice). Was billed the full amount but wrote to the insurance company and they paid it as in network. I know someone suggested talking to the doctor's office manager, but I would suggest talking directly to the doctor. Usually, the doctors are more than willing to discount their fee--and then set up a payment plan. I think they are more willing than their office managers--who can be real bulldogs. As an example, my doctor is out of network (my choice to go to him) and ordered a colonoscopy. I told him I needed a referral to another gastroent. that was in my plan, because I simply could not afford to pay out of network for that procedure. He immediately offered to do the procedure for the fee that my insurance would pay in-network and instructed his office manager to reduce the fee. He also had no problem with me making payments. Believe me, I think the doctors hate the health insurance companies as much as the patients.

Answer 2

Are you assuming the doctor is not in network because you were billed for the balance? Or did you check and found the doctor not to be in network?

Most providers and insurance companies have a contract stating the provider is not to balance bill the member. If the doctor is truly in network and is billing you the balance, he could be breaking the contract with your carrier.

I would call the claims number and ask to talk to someone in "Rapid Resolution" or in "Service Resolution" or go to your group's Plan Administrator in Human Resources or go to the Broker that sold the policy to the group.

I had a similar situation myself. I was told by the local Sales Office, the Health Insurance Company, AND the clinic that the doctor was in-network; turned out he was not. I called the insurance company and told them what happened and they worked something out b/c their staff was incorrect.

You could try that avenue too. You can only go by what you are told and if everyone told you he was in network, what do you do?

Hope this helps.

Answer 3

Hospitals and doctors in hospitals are totally separate entities (as are labs, x-rays. etc.) and one can be out of network, even if the other is.

As a patient, except in an emergency situation, it is your responsibilty to know what providers are in your network and use them.

Call the billing manager, tell them you need a week to research the bill and you will get back to them.

If the doctor has already been paid by your insurance company, you need to get a copy of the Explanation of Benefits from your insurance company RIGHT AWAY. If the plan paid it as if the doctor was in-network and has the remainder as a provider discount, then you need to call your insurance right away and complain to them, and the doctor will be told they can not bill you. (It will clearly state "patient not responsible" on it.) If the insurance is putting a portion of the bill to an out of network deductible (many plans have them) then you need to do one of two things: 1. file an appeal (based on circumstances of why you saw this doctor - was it in the ER or does he do something no other participating doctor does?) with the plan to get it paid as in-network. Or 2. Suck it up and make a payment plan to the provider. (If you knowingly saw this doctor, and there's nothing special about what he or she does, you're on the hook.)

Answer 4

try Don's suggestion. However, if the doctor (being out of plan) was simply rejected by your insurance carrier and they paid nothing, you are likely on the hook for something to the physician.

While you'll still hot about this -- write to your state legislators [I assume you're an American].

This sort of unfair billing practice while you are not in a position to shop [ER, or significantly ill] for a doctor is something they should have addressed a long, LONG time ago.

What they need to do is pass a law limiting physicians' charges [except for cases where there is no medical need] so that doctors (and all other providers) have to charge everyone the same. Then comparison shopping would be possible in non-emergency situations.


GL

{Btw -- have you seen any of our oh so important politicians say anything about this? NO of course not -- their health plans don't have these loopholes. How out of touch with the average Joe are they? COMPLETELY.}

:-)

Answer 5

Unfortunately it is up to you to check your coverage and plan requirements, not the hospital. So, regardless of what they told you, you are responsible to pay the doctor. In most cases, the hospital bills for the hospital services. Doctors bill their charges separately, not through the hospital. So, the hospital probably told you that you were fully covered for their charges and you may have assumed that included the doctors charges. They have no responsibility to check to see how your plan works with any particular doctor.

Answer 6

When I was a claims processor, we covered all bills as in-network as long as the hospital was in the network. I mean, when you're actually INPATIENT, you don't have much control over which doctors treat you.

File an appeal with your insurance. This should be covered at the in-network rate.

Answer 7

Call his office manager and explain exactly what happened. Tell her that you simply cannot afford the difference in payment. They will either forgive the difference or try to work out some kind of payment plan.

Answer 8

Once again the insurance industry is bleeding another working citizen. It's ashamed! I would contact the insurance company directly. Depending on the company, they will go out of their way to help you. But, you must persevere. They will try and work you overtime. Most people will just throw in the towel. Don't give up! Follow through and you will win. Good luck!