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Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 7:56 pm
by DinkinFlicka
A health care provider I started seeing is an in-network provider. However, at the first visit, they said that they are choosing to bill my insurance as an out of network provider, but I will still only be subject to my in-network deductible and required to pay my in-network copay.

I'm supposed to bring in whatever checks and EOBs I get in the mail into the provider. Any additional "patient responsibility" is waived.

Is this normal? I'm getting the feeling they are doing this because out-of-network reimbursements might be higher than in-network rates but was curious whether this is actually allowed by the insurance company (BCBS).

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 7:59 pm
by 6Pack
As a general rule of thumb I live by, I don’t lie for other people.

This isn’t a standard practice that I’m aware of and may be fraudulent. Just my $0.02.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:06 pm
by CoastalWinds
DinkinFlicka wrote:
Tue Aug 13, 2019 7:56 pm
A health care provider I started seeing is an in-network provider. However, at the first visit, they said that they are choosing to bill my insurance as an out of network provider, but I will still only be subject to my in-network deductible and required to pay my in-network copay.

I'm supposed to bring in whatever checks and EOBs I get in the mail into the provider. Any additional "patient responsibility" is waived.

Is this normal? I'm getting the feeling they are doing this because out-of-network reimbursements might be higher than in-network rates but was curious whether this is actually allowed by the insurance company (BCBS).
OMG, this ain’t right. I wouldn’t go for it. I certainly hope this isn’t a new trend in the industry.

Also, many insurance plans separately track in- vs out-of network costs, deductibles, OOP maximums, etc. If you’re always trying to stay in-network, this would be forcing you to “split the baby”.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:10 pm
by Xaran
Typically there is a contract between either the provider or the company that they work for that determines what they are allowed to bill and whether they are in-network or out of network. This sounds extremely fishy to me. My last job I was heavily involved in medical coding and billing and working with insurance companies, and this would have sent up all sorts of red flags for me at work. But it is dictated by the contract that the provider has with the insurance company, so if the insurance company allows it then they might be able to, but I can't see any insurance company setting up a provider as in-network and then telling them it is ok to bill out of network, especially Blue Cross, which in my experience was one of the strictest ones out there.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:11 pm
by flamesabers
This sounds a bit suspicious. Without knowing the precise details of your plan, it's impossible to know exactly why your provider is trying to do this.

My recommendation is to contact your insurance company immediately. There could potentially be a bit of delay with getting your claims paid due to the mismatch of the hospital billing as out-of-network despite being in-network with your insurance.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:13 pm
by stan1
I'd switch to a different doctor/provider.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:18 pm
by ResearchMed
stan1 wrote:
Tue Aug 13, 2019 8:13 pm
I'd switch to a different doctor/provider.
Something is off.

I want physicians that I can trust as much as possible.
I'd like to be able to trust all vendors, but "bankers" and medical personnel"... most of all.
And actually, yeah, medical at the top.

RM

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:24 pm
by DinkinFlicka
Xaran wrote:
Tue Aug 13, 2019 8:10 pm
Typically there is a contract between either the provider or the company that they work for that determines what they are allowed to bill and whether they are in-network or out of network. This sounds extremely fishy to me. My last job I was heavily involved in medical coding and billing and working with insurance companies, and this would have sent up all sorts of red flags for me at work. But it is dictated by the contract that the provider has with the insurance company, so if the insurance company allows it then they might be able to, but I can't see any insurance company setting up a provider as in-network and then telling them it is ok to bill out of network, especially Blue Cross, which in my experience was one of the strictest ones out there.
This might be the case. I didn't fully understand what the receptionist when she handed me the forms, but it did sound like she said "we have a contract (or are under contract?) with BCBS and choose to bill as out-of-network". FWIW, the provider is pretty large with multiple locations across NYC.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:42 pm
by Xaran
The other thing I would worry about with this scheme would be how your insurance company chooses to apply this to your out of pockets and deductible. Many insurance companies will not apply out of network charges towards either of these. That could affect you financially in a significant way.

Something is very fishy if the receptionist is telling you this. Blue Cross doesn't set you up as an in-network provider on a contract and then simply "allow" you to bill as out of network. They pay based on rates stipulated in the contract. This sounds to me like a provider who thinks he has found a clever way of working around stuff to get more reimbursement. I've seen this happen with a lot of providers, and insurance companies inevitably come down on them for it. And as I said before, it could have some really negative consequences for you financially as well. If it were me personally, I would not agree to allow them to do this without a very good and detailed explanation of how their contract with Blue Cross allows them to do this and how it would affect me financially. And I would definitely do what flamesabers said. Contact your insurance company and tell them the exact doctor and office that is trying to do this and find out if it is ok before ever going to this doctors office for a visit.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 8:57 pm
by whodidntante
File a complaint with the insurance company about this provider. I would do it in a letter and forward the same letter to your state insurance bureau of bureaucracy or whatever the bringer of doom might be called in your great state.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 9:08 pm
by Watty
I would wonder if the doctor and the insurance company are in the process of ending the "in network" relationship. You may have even made the appointment while they were in-network but by date of your appointments and possible follow ups they may no longer in network so they are grandfathering you in at the in network rates.

I would contact the insurance company to ask about this.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 9:35 pm
by MP123
It may be that they are out of network with BCBS but are willing to extend in network co-pays to you. They may be doing you a favor in other words to get your business for the higher reimbursement rates.

They don't have much to say about how BCBS applies your deductible though so that's a little odd but perhaps a misunderstanding somewhere.

Assuming you're happy with the provider otherwise I'd check it out with BCBS to see if they are in fact in network.

I wouldn't assume this is a fraudulent situation, nothing is really "normal" in healthcare insurance any more.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 9:48 pm
by Nowizard
Certainly it sounds questionable, but no one here knows. If you like the physician, there is no need to poison the water initially. It is a simple process to call your insurance company and ask if the provider is in or out of network, following it up by asking how the difference affects you. If the company says he is in network, then you can follow up by asking the obvious question of whether he is allowed to bill out-of-network. Very likely that there is something unallowable here. Another aspect of this issue is that the office said you would not be responsible for additional charges. That is balance billing. All insurance companies with whom I had a contract before retirement would definitely disallow balance billing if known. It is common, for example, that some patients are forgiven their co-payment for various reasons. It is not allowed by contract. If the co-payment is, for example, $20.00, the provider is contractually required to reduce the amount billed by that amount.

Tim

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 9:50 pm
by southerndoc
You verified the provider is in-network?

There are 2 possible scenarios:

1. Your state has a balance billing law and the out-of-network rate is higher than his/her negotiated in-network rate.

2. He/she is billing a higher amount with an out-of-network rate, accepting an in-network payment amount, and then deducting the unpaid amount from his/her taxes.

Either way, I don't believe it is right. Who would trust their healthcare to someone who is asking a patient to help him/her do something shady and possibly fraudulent?

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 11:00 pm
by toofache32
I agree this sounds strange. Another possibility: I am a surgeon with 2 jobs. One is my private practice and the other is in a hospital institutional setting. In my private practice, I am not in-network with any insurance. In my hospital job, I am in-network with almost every plan. Sometimes patients come to my private practice because they found my name on their insurance website as in-network. But they didn't look to see that's at a different address (hospital).

If this doctor is contracted with BCBS to be in-network at the location you saw him/her then I don't see how this isn't fraud. I also don't see how the insurance would accept an "out of network" claim for a doctor they have on record as being "in-network" at that office.

Re: Provider choosing to bill as out of network

Posted: Tue Aug 13, 2019 11:25 pm
by sawdust60
The provider is not part of the network, so they bill your insurance company what they want. The insurance company pays what they want, perhaps based on their reasonable and customary guidelines. You pay a copay to the provider, as the provider agreed to accept the in-network amount on your policy.

It is confusing, but I think this approach is better than the provider expecting you to make up for any shortfall by the insurance company.

Could this be a first step in the elimination of networks? Any provider that expects to be paid more than the in-network copay, should collect it in advance -- while you have an opportunity to decline.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 1:15 am
by toofache32
sawdust60 wrote:
Tue Aug 13, 2019 11:25 pm
The provider is not part of the network, so they bill your insurance company what they want....
The OP said the provider IS in-network. But I would be interested in how they determined that. I dropped some networks 4 years ago but I am still listed on their websites. They do this on purpose to look like they have more doctors than they really do.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 6:54 am
by DinkinFlicka
southerndoc wrote:
Tue Aug 13, 2019 9:50 pm
You verified the provider is in-network?
toofache32 wrote:
Wed Aug 14, 2019 1:15 am
The OP said the provider IS in-network. But I would be interested in how they determined that.
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 7:08 am
by JPH
I would contact the insurer to try and find out what is going on. Confirm that the doctor was in network on the day of your visit. The website could be out of date. My BCBS plan has patient representatives that are very helpful and easy to work with.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 7:09 am
by toofache32
DinkinFlicka wrote:
Wed Aug 14, 2019 6:54 am
southerndoc wrote:
Tue Aug 13, 2019 9:50 pm
You verified the provider is in-network?
toofache32 wrote:
Wed Aug 14, 2019 1:15 am
The OP said the provider IS in-network. But I would be interested in how they determined that.
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.
I bet they are not really in network. You should ask the doctors office also, see my note above.
Just yesterday I received a letter saying “congratulations you’re now in network with Amerigroup!” although I never asked to be. Trying to figure that one out.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 7:11 am
by Mako
DinkinFlicka wrote:
Wed Aug 14, 2019 6:54 am
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.
This isn't always accurate. My insurance website explicitly warns (like toofache said above) that providers may not be in network at all locations and also says I need to verify with the provider to confirm if they are in network. And, as toofache also said, the information may be stale--I had a doc leave the network and he was still on the website until the next year, it appeared that they update it once a year.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 7:13 am
by furwut
DinkinFlicka wrote:
Wed Aug 14, 2019 6:54 am
southerndoc wrote:
Tue Aug 13, 2019 9:50 pm
You verified the provider is in-network?
toofache32 wrote:
Wed Aug 14, 2019 1:15 am
The OP said the provider IS in-network. But I would be interested in how they determined that.
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.
Unfortunately that is not always determinative. Provider directory listings are constantly changing and notoriously inaccurate.

I’ve had an insurer tell me a doctor was in network. Checked with doctor and they agreed. Months later bill comes as out-of-network.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 7:40 am
by Jack FFR1846
furwut wrote:
Wed Aug 14, 2019 7:13 am
DinkinFlicka wrote:
Wed Aug 14, 2019 6:54 am
southerndoc wrote:
Tue Aug 13, 2019 9:50 pm
You verified the provider is in-network?
toofache32 wrote:
Wed Aug 14, 2019 1:15 am
The OP said the provider IS in-network. But I would be interested in how they determined that.
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.
Unfortunately that is not always determinative. Provider directory listings are constantly changing and notoriously inaccurate.

I’ve had an insurer tell me a doctor was in network. Checked with doctor and they agreed. Months later bill comes as out-of-network.
This is quite true and we run into it all the time. Working with the Cigna network website AND being on the phone with the Cigna rep, we were looking for a doctor. We confirmed our first 4 choices from the website with the Cigna rep on the phone. We then started calling and NONE of these 4 were available. They were moved, retired, dead or the practice had closed. All of them! Buncha incompetent morons.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 8:05 am
by 8foot7
sawdust60 wrote:
Tue Aug 13, 2019 11:25 pm
The provider is not part of the network, so they bill your insurance company what they want. The insurance company pays what they want, perhaps based on their reasonable and customary guidelines. You pay a copay to the provider, as the provider agreed to accept the in-network amount on your policy.

It is confusing, but I think this approach is better than the provider expecting you to make up for any shortfall by the insurance company.

Could this be a first step in the elimination of networks? Any provider that expects to be paid more than the in-network copay, should collect it in advance -- while you have an opportunity to decline.
The problem is that if the doctor is truly in-network but bills as out-of-network, the insurance company may apply amounts to deductibles and coinsurance that apply to out-of-network doctors, giving the insured/patient no credit towards in-network deductibles or benefits. Admittedly this means little if there is no deductible for in-network providers, but many policies have some deductibles and out of pocket limits for in-network that are more advantageous to the patient/insured and if the doctor is billing around that while taking advantage of their placement as an in-network doctor, the patient is getting screwed as well.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 8:06 am
by perplexed
From personal experience, unless the insurance goes into a specific contract with your provider for your case, this arrangement is dangerous and fraught with lots of worries. We had our insurance go into such a contract, and most things got cleared as in-network, but not before constant problems with bills escaping in-network arrangements.

If you have a specific reason to only choose this provider, please try to see if your insurance will cover as in-network.

If you live in a state where balance billing is allowed, this can easily snowball into a massive cash drag.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 8:12 am
by Point
Seems to me you’d want to talk with your insurance provider and verify this is appropriate. They are backing your financial exposure.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 9:12 am
by GrowthSeeker
DinkinFlicka wrote:
Wed Aug 14, 2019 6:54 am
Yes, the provider is in-network. I verified by going to BCBS's website and using the "Find a doctor" search.
An insurance company's website is not the most reliable source of information.

Unless you've already done it, I would speak to someone higher up in the billing department of the physician's office and get at least their version of a detailed explanation.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 9:24 am
by HomeStretch
Is it an office with multiple doctors where only some are in-network?

Did the doctor recently drop out of the network?

Insurers have multiple plans. Did you check the provider network for the right one? Is your doctor possibly only in-network for some of Insurer A’s plans (and not yours)?

You need to talk with the provider’s billing department and insurance company to determine whether the doctor was in-network on your visit date and whether the service was billed/paid as in or out-of-network. This is such an odd situation I would want to verify/re-verify my facts that an in-network doctor is billing as an out-of-network provider.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 10:27 am
by toofache32
perplexed wrote:
Wed Aug 14, 2019 8:06 am
If you live in a state where balance billing is allowed, this can easily snowball into a massive cash drag.
Balance billing is related to (usually) emergency care when there is no way to create a contract between the doctor and patient prior to treatment.
In an office setting, that contract is in place with a signed financial agreement ahead of time.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 8:27 pm
by megabad
DinkinFlicka wrote:
Tue Aug 13, 2019 7:56 pm
I'm supposed to bring in whatever checks and EOBs I get in the mail into the provider.
I would not do this. I tell all providers to just deal with the insurance company. When I see an EOB that is wrong, I call the insurance company and they deal with the provider. Basically, I follow the rules.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 8:41 pm
by JPM
Any doctor who did something like this would jeopardize his/her employment in a large group and perhaps jeopardize the group's Blue Cross contract. Continuation of the group's contract with BC would probably be contingent on dismissing the doctor. My first thought is that this is part of an embezzlement scheme on the part of some of the clinic staff. During periods of low unemployment, clinics sometimes have to hire marginal personnel to replace leavers and make the best of it. Unless they have made their clinic a sufficiently good place to work that your good personnel will not leave. Whatever is going on is not usual practice.

Re: Provider choosing to bill as out of network

Posted: Wed Aug 14, 2019 9:26 pm
by toofache32
I'm still not convinced this doctor is in-network. It's not as simple as seeing the doctor's name on the insurance website.

Re: Provider choosing to bill as out of network

Posted: Thu Aug 15, 2019 7:47 am
by DinkinFlicka
toofache32 wrote:
Wed Aug 14, 2019 9:26 pm
I'm still not convinced this doctor is in-network. It's not as simple as seeing the doctor's name on the insurance website.
I called BCBS and confirmed that the provider was in-network. The provider also told me when I went in for my first visit that they are in-network and are choosing to bill me as out-of-network. If there's a better way to determine whether they are in-network, please let me know.

Like others have mentioned, BCBS said it's possible that the location is in-network but the individual doctors are not. That said, scheduling for my visits was done after my first visit and who I see changes between visits (this is physical therapy).

Re: Provider choosing to bill as out of network

Posted: Thu Aug 15, 2019 8:15 am
by nisiprius
DinkinFlicka wrote:
Tue Aug 13, 2019 7:56 pm
A health care provider I started seeing is an in-network provider. However, at the first visit, they said that they are choosing to bill my insurance as an out of network provider, but I will still only be subject to my in-network deductible and required to pay my in-network copay.

I'm supposed to bring in whatever checks and EOBs I get in the mail into the provider. Any additional "patient responsibility" is waived.
A very important question is: will they give this to you in writing? If you really want to continue with this doctor and this practice, then, yes, you should really get it in writing.

In the case where this is completely legitimate and on the up-and-up, they should be willing to give it to you in writing.

If it is verbal, nudge-nudge, wink-wink, don't worry, we won't actually hold you responsible for the bill, then I wouldn't do it. Not only are there questions about whether they are cheating, but there is also the possibility that later the person who made the promise won't be with them, and someone else may disavow the promise.

Now if you ask them to put it in writing, they might be all like "oh, we never thought to put this in writing, none of our other patients has ever wanted that." Prepare for this in advance. Write down a simple plain-language description, in non-legal language, of what you think the deal is, and ask them to have someone sign it. To make it as non-intimidating as possible, make it handwritten! It should be just about the same as what you have written above:

"I understand that you will be choosing to bill my insurance as an out of network provider. I understand that I will still only be subject to my in-network deductible and required to pay my in-network copay, and that you waive any other "patient responsibility." In return, I agree to supply you with any checks and EOBs I get in the mail."

The point is that you want to get a permanent and clear record of the promise, yet keep it sloppy and informal so that they will not think you are planning to spring some kind of legal maneuver on them.

A sloppy, informal record is good enough to show to someone--a different person a year later, maybe, who has no idea if the promises were really made, or whether it was just wishful thinking on your part.

I have really done this in the past in a handful of situations, where there was a verbal promise that was important to me that I didn't have in writing. About half the time, the other person has looked it over carefully and said, "yes, that's right," and signed it. About half the time, though, the response has been something I'd describe as "freaking out." And then of course, that was the end of the deal.

Re: Provider choosing to bill as out of network

Posted: Thu Aug 15, 2019 9:58 am
by cherijoh
DinkinFlicka wrote:
Tue Aug 13, 2019 7:56 pm
A health care provider I started seeing is an in-network provider. However, at the first visit, they said that they are choosing to bill my insurance as an out of network provider, but I will still only be subject to my in-network deductible and required to pay my in-network copay.

I'm supposed to bring in whatever checks and EOBs I get in the mail into the provider. Any additional "patient responsibility" is waived.

Is this normal? I'm getting the feeling they are doing this because out-of-network reimbursements might be higher than in-network rates but was curious whether this is actually allowed by the insurance company (BCBS).
I'd find another doctor. I don't see how this is even possible, since the insurance company would know whether or not they were in- or out-of-network for your insurance plan. I don't think the provider gets a choice if they actually are in-network. But if BCBS didn't pick up on it, I would consider this to be fraud.

Are you sure you understood properly? BCBS has a boatload of plans and some doctors are only in some of the BCBS plans, so you have to check carefully to see if your doctor is participating for the particular plan that you have. If they particpate in some BCBS plans but not yours, they could legitimately charge for out-of-network but to retain customers might offer to let you pay as if you were in-network. Another possibility is that they used to be in-network and the contract was changed so that they no longer are.

However, as a practical matter, my health insurance has a different out-of-pocket maximum for out-of-network - I think it's double the in-network one. So I would look for someone who is in-network and will be filing as such.

EDIT: I see from your other post that this is for PT. They may have therapists that aren't in the network, but it still sounds like a scam. The only time I've had out-of-network billing at an in-network facility was for the anesthesiologist for an out-patient procedure. In that case, the doctor, facility and anesthesiologist all billed separately, so I got 2 in-network and 1 out-of-network EOB.

I'd find a PT office that will guarantee that they will bill as in-network because of the out-of-pocket maximums.

Re: Provider choosing to bill as out of network

Posted: Fri Aug 23, 2019 1:54 am
by DinkinFlicka
cherijoh wrote:
Thu Aug 15, 2019 9:58 am
I see from your other post that this is for PT. They may have therapists that aren't in the network, but it still sounds like a scam.
Got the first claim details and EOB. It looks like the provider listed was a specific therapist, not the general provider. This is different than PT I've had in the past at a different location, where the provider on the claim was the general physical therapy location which was in-network. The first EOB had some additional CPT codes for the first visit, so it's hard to compare this current EOB with that past one, but I'm curious if I'll see providers getting paid more in this out-of-network route (not sure if it's possible to accurately compare across providers though).
cherijoh wrote:
Thu Aug 15, 2019 9:58 am
I'd find a PT office that will guarantee that they will bill as in-network because of the out-of-pocket maximums.
I'm in a situation where I have a $0 in-network deductible as well as a $0 in-network out-of-pocket maximum, so I think it's actually beneficial that I'm fulfilling my out-of-network deductible and out-of-network out-of-pocket maximum while only paying my in-network copay. I also got in writing from the provider that they would only be charging me the in-network copay.