Health Insurance Out of Network question

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munemaker
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Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 4:00 pm

My health insurance has very good coverage within a network of providers, but no out of network coverage.

Recently I had a colonoscopy. Prior to the colonoscopy, I called the insurance company if it would be covered and they said yes it would. I asked about the possibility of out of network doctors or anesthesiologists and was told that if the procedure was performed in one of the facilities they cover, the doctors would all be covered...

So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.

I am thinking I need to try to negotiate a reduction with the pathologist. I am sure no insurance company would pay anywhere near the amount I am billed. So how to go about this? Should I call or write? Should I ask for a specific reduction or just ask for a discount? If I am declined, should I try to elevate it?

No experience with this. Any advice would be appreciated.

Thanks

JBTX
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Re: Health Insurance Out of Network question

Post by JBTX » Sat Dec 16, 2017 4:16 pm

I think this has come up before

viewtopic.php?t=205132

viewtopic.php?t=196871

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 5:57 pm

JBTX wrote:
Sat Dec 16, 2017 4:16 pm
I think this has come up before

viewtopic.php?t=205132

viewtopic.php?t=196871
Thanks for the links, but they were not that helpful. The first one was an emergency situation, where mine was not. The second one was where the OP followed a recommendation for a test that turned out to be out of network.

In my situation, the facility, anesthesia, lab doctor were in network, but the polyps were handed off to an out of network pathologist for review without my knowledge; I had no idea until the bill showed up. One alternative is to shut up and pay it. However, it just doesn't seem right so I am wondering what other recourse I have. It is hard to know who to blame in this situation The doctor performing the procedure told me in advance to make sure my insurance would cover it. Well, how do you know what twists and turns are going to happen and who they might pull into the situation? Should I have had the insight to ask, if you find something, who are you going to pass it off to and are then check with the insurance company to see if they were in network? How can you protect yourself in these situations?

Also, interesting that the bill is marked that I do not have insurance. I would have thought they would have turned it into my insurance, an EOB would have been processed and it would be denied as being out of network? Shouldn't that have occurred? Or maybe since they know they are out of network, they just skip that part of the process?

Confused!

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HueyLD
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Re: Health Insurance Out of Network question

Post by HueyLD » Sat Dec 16, 2017 6:11 pm

You need to review your own insurance contract because every insurance policy is different.

It appears that you have an EPO style of insurance. Even in such an insurance, there may be provisions for the insurance to pay benefits at in-network levels for services provided in an authorized facility by out of net work medical providers such as radiologists, CRNAs, pathologists, assistant surgeons, anesthesiologists, etc. You are still responsible for the balance billing unless your state has a law against balance billing.

Good luck. Our medical system is a mess.

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dm200
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Re: Health Insurance Out of Network question

Post by dm200 » Sat Dec 16, 2017 6:16 pm

munemaker wrote:
Sat Dec 16, 2017 4:00 pm
My health insurance has very good coverage within a network of providers, but no out of network coverage.
Recently I had a colonoscopy. Prior to the colonoscopy, I called the insurance company if it would be covered and they said yes it would. I asked about the possibility of out of network doctors or anesthesiologists and was told that if the procedure was performed in one of the facilities they cover, the doctors would all be covered...
So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.
I am thinking I need to try to negotiate a reduction with the pathologist. I am sure no insurance company would pay anywhere near the amount I am billed. So how to go about this? Should I call or write? Should I ask for a specific reduction or just ask for a discount? If I am declined, should I try to elevate it?
No experience with this. Any advice would be appreciated.
Thanks
I would start with your insurance company, review exactly what you were told and when you were told. Reiterate that the procedure was performed in a facility they cover. It seems you did everything correctly to do your best in having in network providers.

How do you know that this pathologist is/was out of network? Also, read all the fine print of your policy - sure seems that there should be some degree of coverage if/when an in network provider is not available.

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runner9
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Re: Health Insurance Out of Network question

Post by runner9 » Sat Dec 16, 2017 6:18 pm

I would call the insurance company first, explain the situation, push a little and listen to their advice. Based on that you could appeal to insurance, negotiate with the doctor, etc.

ResearchMed
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Re: Health Insurance Out of Network question

Post by ResearchMed » Sat Dec 16, 2017 6:26 pm

munemaker wrote:
Sat Dec 16, 2017 5:57 pm
JBTX wrote:
Sat Dec 16, 2017 4:16 pm
I think this has come up before

viewtopic.php?t=205132

viewtopic.php?t=196871
Thanks for the links, but they were not that helpful. The first one was an emergency situation, where mine was not. The second one was where the OP followed a recommendation for a test that turned out to be out of network.

In my situation, the facility, anesthesia, lab doctor were in network, but the polyps were handed off to an out of network pathologist for review without my knowledge; I had no idea until the bill showed up. One alternative is to shut up and pay it. However, it just doesn't seem right so I am wondering what other recourse I have. It is hard to know who to blame in this situation The doctor performing the procedure told me in advance to make sure my insurance would cover it. Well, how do you know what twists and turns are going to happen and who they might pull into the situation? Should I have had the insight to ask, if you find something, who are you going to pass it off to and are then check with the insurance company to see if they were in network? How can you protect yourself in these situations?

Also, interesting that the bill is marked that I do not have insurance. I would have thought they would have turned it into my insurance, an EOB would have been processed and it would be denied as being out of network? Shouldn't that have occurred? Or maybe since they know they are out of network, they just skip that part of the process?

Confused!
I'm curious about it already being marked that you have no insurance.

Are you sure it was ever submitted, that the provider even tried to collect from insurance?
(If not, maybe they'd get less from insurance and are trying... um...?)

For starters, I'd double check that it isn't already in network and somehow that was overlooked.
If not, then I'd go back and re-visit that call where you were told it would "all" apparently be covered, etc., if at the right facility.
Maybe there is not really any problem here, except that the provider didn't know about your insurance coverage.

Good luck.

RM
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dm200
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Re: Health Insurance Out of Network question

Post by dm200 » Sat Dec 16, 2017 6:30 pm

Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?

OnTrack2020
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Re: Health Insurance Out of Network question

Post by OnTrack2020 » Sat Dec 16, 2017 6:39 pm

We've had a situation where our daughter had surgery on a recurring basis, and we were at the mercy of who they assigned to her. We had no control over the situation. In that case, we could either send an appeal to our insurance company. If the insurance company denied the appeal, the provider typically would reduce the charge to the in-network rate.

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dm200
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Re: Health Insurance Out of Network question

Post by dm200 » Sat Dec 16, 2017 7:10 pm

OnTrack2020 wrote:
Sat Dec 16, 2017 6:39 pm
We've had a situation where our daughter had surgery on a recurring basis, and we were at the mercy of who they assigned to her. We had no control over the situation. In that case, we could either send an appeal to our insurance company. If the insurance company denied the appeal, the provider typically would reduce the charge to the in-network rate.
Who or what is "they" that does the assigning? This sounds like important, but not immediate type surgery - so it seems to me that the insurance company would or should have or provide a qualfied surgeon either on the plan or agree to pay (and charge you) as though he/she was on the plan.

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Re: Health Insurance Out of Network question

Post by blmarsha123 » Sat Dec 16, 2017 8:21 pm

dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.

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Re: Health Insurance Out of Network question

Post by marcopolo » Sat Dec 16, 2017 9:23 pm

munemaker wrote:
Sat Dec 16, 2017 4:00 pm
My health insurance has very good coverage within a network of providers, but no out of network coverage.

Recently I had a colonoscopy. Prior to the colonoscopy, I called the insurance company if it would be covered and they said yes it would. I asked about the possibility of out of network doctors or anesthesiologists and was told that if the procedure was performed in one of the facilities they cover, the doctors would all be covered...

So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.

I am thinking I need to try to negotiate a reduction with the pathologist. I am sure no insurance company would pay anywhere near the amount I am billed. So how to go about this? Should I call or write? Should I ask for a specific reduction or just ask for a discount? If I am declined, should I try to elevate it?

No experience with this. Any advice would be appreciated.

Thanks
I recently went through a similar experience with the Anesthesiologist for my Colonoscopy (viewtopic.php?f=2&t=220130&p=3617441#p3617441). It took many months to resolve, but the good news was that the insurance company and the provider worked this out with any real involvement on my part. Hope you have an equally satisfying outcome
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celia
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Re: Health Insurance Out of Network question

Post by celia » Sat Dec 16, 2017 9:31 pm

munemaker wrote:
Sat Dec 16, 2017 4:00 pm
So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.
You should never pay a medical bill until you receive the EOB. What did the EOB say?

Once you pay the bill, they have no incentive to bill the insurance.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 9:37 pm

blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.

I do not doubt that I may be on the hook for the entire amount. I am just looking for a validate the charges and mitigate them to the degree possible, if at all.

I also wonder why it was not submitted to the insurance company even if it resulted in a denial. They probably know they are out of network and are possibly just avoiding the paperwork.

Also, I am wondering what I could/should have done to prevent this from happening.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 9:39 pm

celia wrote:
Sat Dec 16, 2017 9:31 pm
munemaker wrote:
Sat Dec 16, 2017 4:00 pm
So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.
You should never pay a medical bill until you receive the EOB. What did the EOB say?

Once you pay the bill, they have no incentive to bill the insurance.
OP here. I think I stated in the original post that the bill said I have no insurance coverage and obviously there would be no EOB if it was not submitted. Should I have the pathologist submit to the insurance company? That's what you are saying, so unless someone else has an opposing view, I will do that.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 9:43 pm

dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
OP here. This is an EPO, and the policy makes it clear there is no out of network coverage except for emergencies.

My problem is that I did not select this pathologist. Someone else did. I imagine it was the surgeon who performed the procedure, but I don't know that for sure. Bill came today (Saturday). I will try to find out how this happened on Monday.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 9:49 pm

ResearchMed wrote:
Sat Dec 16, 2017 6:26 pm

I'm curious about it already being marked that you have no insurance.

Are you sure it was ever submitted, that the provider even tried to collect from insurance?
(If not, maybe they'd get less from insurance and are trying... um...?)

For starters, I'd double check that it isn't already in network and somehow that was overlooked.
If not, then I'd go back and re-visit that call where you were told it would "all" apparently be covered, etc., if at the right facility.
Maybe there is not really any problem here, except that the provider didn't know about your insurance coverage.

Good luck.

RM
OP here.

The bill says I have no insurance coverage and the online insurance website shows no EOB, so I am pretty sure the bill was not submitted to insurance.

As far as the call, there is no real record of it. It was just me and some customer service person on the phone. I should have kept a record of who and when, but I did not. I don't think it would have mattered anyway.

The insurer's website has a search feature for in-network doctors. You can search by the doctor's name or the firm's name. I tried both and neither show as in network, so I am pretty sure they are not.

Someone here suggested making the pathologist turn it into my insurance and have an EOB generated showing it was denied. That would seem to be a good step.

Thanks

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Re: Health Insurance Out of Network question

Post by Jack FFR1846 » Sat Dec 16, 2017 9:54 pm

munemaker wrote:
Sat Dec 16, 2017 9:39 pm

OP here. I think I stated in the original post that the bill said I have no insurance coverage and obviously there would be no EOB if it was not submitted. Should I have the pathologist submit to the insurance company? That's what you are saying, so unless someone else has an opposing view, I will do that.
Yes, call the pathologist and ask that they submit to insurance. I can't tell you how many times we've had to do this even with our regular doctors. Front office people screw up and don't bother submitting. We remind them, they submit, it's paid.

Beyond that, if it's denied by insurance, appeal. If that's denied, go to 2nd level appeal. We've done those too, many times. The system is screwed up and the patient often doesn't have control or knowledge whether someone will be in network. In surgery, a doctor could sub in whose not in network. You're not even conscious. You're still on the hook.
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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sat Dec 16, 2017 9:58 pm

dm200 wrote:
Sat Dec 16, 2017 6:16 pm

I would start with your insurance company, review exactly what you were told and when you were told. Reiterate that the procedure was performed in a facility they cover. It seems you did everything correctly to do your best in having in network providers.

How do you know that this pathologist is/was out of network? Also, read all the fine print of your policy - sure seems that there should be some degree of coverage if/when an in network provider is not available.
Good advice. I will start with the insurance company Monday morning.

The insurance company website has a search feature where you can search for in-network doctors by name or by the name of the firm they are associated with. I tried both and neither come up in network. Certainly not 100% conclusive, but probably correct. Still, needs validated.

This is an EPO and there is clearly no out-of-network coverage except for emergencies.

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celia
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Re: Health Insurance Out of Network question

Post by celia » Sat Dec 16, 2017 10:09 pm

The doctor who did the colonoscopy probably sends all his labwork to the same pathologist for review. There doesn't seem to be anything special about your case compared to the HMO patient who went before or after you. And not all doctors are shown in the insurance company network database. For example, anesthesiologists and ambulance service is never shown. But they are covered by the insurance. Do you think your insurance wanted you to have a colonoscopy without an anesthesiologist or not have a pathologist/lab review the sample? Just confirm with insurance that they haven't been billed yet and ask them what the next step should be.

In the worst case, their computer will kick out the claim and the EOB will say "out-ot-network". At that point, you can call up the insurance company and ask that they review this claim. If need be, file an appeal over the phone. But, of course, they will not pay if they have not been billed.

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Re: Health Insurance Out of Network question

Post by blmarsha123 » Sat Dec 16, 2017 10:29 pm

munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.

I do not doubt that I may be on the hook for the entire amount. I am just looking for a validate the charges and mitigate them to the degree possible, if at all.

I also wonder why it was not submitted to the insurance company even if it resulted in a denial. They probably know they are out of network and are possibly just avoiding the paperwork.

Also, I am wondering what I could/should have done to prevent this from happening.
I understand. I remember considering an EPO at one time because of the (lower) premiums vs other choices. However, when researching during the enrollment period, I was never satisfied with the answers about what constituted going out of the EPO network, in two specific situations: (1) During surgery, an out of network consulting physician is brought in; and (2) Lab results going to an out of network lab. Both of these situations happened to me before, and both times they were charged against my out of network coverage. The EPO sales rep. stated over and over "that should never happen with our EPO providers." Right. Needless to say, I did not go with the EPO.

Anyway, to your point, I am not sure that there is anything that you could have done to prevent the situation. But I would definitely appeal to the EPO because the EPO surgeon sent the results to a non-EPO lab. That is a failure in the EPO process that you should not have to pay for.

toofache32
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Re: Health Insurance Out of Network question

Post by toofache32 » Sat Dec 16, 2017 11:30 pm

munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.
celia wrote:
Sat Dec 16, 2017 10:09 pm
The doctor who did the colonoscopy probably sends all his labwork to the same pathologist for review.
The surgeon doesn't "send" it to anyone but the nurse in the room.... who drops it in a bucket and walks it down to the path lab. One of my hospitals just started outsourcing ALL their pathology to an off-site 3rd party in town since they were losing money from insurance payments. The surgeon has no say in this and often doesn't even know.

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celia
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Re: Health Insurance Out of Network question

Post by celia » Sun Dec 17, 2017 2:51 am

Of course the doctor knows who usually does the lab work since he gets the report back from the pathologist. I believe the lab/pathologist needs "orders" or a request from a doctor (even though someone else transports it).

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Sun Dec 17, 2017 8:44 am

toofache32 wrote:
Sat Dec 16, 2017 11:30 pm
munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.
celia wrote:
Sat Dec 16, 2017 10:09 pm
The doctor who did the colonoscopy probably sends all his labwork to the same pathologist for review.
The surgeon doesn't "send" it to anyone but the nurse in the room.... who drops it in a bucket and walks it down to the path lab. One of my hospitals just started outsourcing ALL their pathology to an off-site 3rd party in town since they were losing money from insurance payments. The surgeon has no say in this and often doesn't even know.
OP here.

The surgeon's name is referenced on the bill in this format: REF. PHYS. SMITH, JOHN J (not his real name)

I know...does not necessarily mean he made the decision.

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Re: Health Insurance Out of Network question

Post by toofache32 » Sun Dec 17, 2017 8:30 pm

celia wrote:
Sun Dec 17, 2017 2:51 am
Of course the doctor knows who usually does the lab work since he gets the report back from the pathologist. I believe the lab/pathologist needs "orders" or a request from a doctor (even though someone else transports it).
Yes the doctor gets the report back and sees the name of the pathologist. But the doctor does not know if the hospital or someone else employs that pathologust. Yes an order is placed into the hospital EMR for the pathology request. Then the hospital does with it what they want. For some reason, everyone thinks the surgeon is the ringleader of some scam.

2015
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Re: Health Insurance Out of Network question

Post by 2015 » Sun Dec 17, 2017 9:17 pm

munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.

I do not doubt that I may be on the hook for the entire amount. I am just looking for a validate the charges and mitigate them to the degree possible, if at all.

I also wonder why it was not submitted to the insurance company even if it resulted in a denial. They probably know they are out of network and are possibly just avoiding the paperwork.

Also, I am wondering what I could/should have done to prevent this from happening.
Here's what I did.

As a result of reading threads here regarding these type of surprise billing problems, when signing initial paperwork in my colonoscopy doctor's office I specifically wrote at the bottom (something like) I did not authorize any procedure that was not covered by my insurance company. When I received a $250 bill almost 4 months after the colonoscopy for something like a copay, I protested to the doctor's billing department that this was a surprise bill as I was not informed of any such amount required and had paid my regular specialist copay for the office visit. I kept copious notes of who I spoke to, including date, time of day, and what was said.

Turns out the billing department was highly disorganized, didn't honor any of their promises to either investigate or get back to me, and continued to send me not only bills with $250 copay whatever, but added other charges as well. I complained not only to the insurance carrier, but to the HMO medical group, my PCP's office, and anywhere else I could think of. I threatened to take my case to the CA Dept of Managed Care. This went on for almost 7 months after my January procedure, but concluded with my insurer agreeing to pay the charge to the doctor's office as a "one time courtesy". As a result of their investigation, the additional errant charges were reversed as well. My insurer at the time, Aetna, was surprisingly outstanding at investigating and responding to my escalated complaint.

I did follow up with formal complaints to Aetna, my PCP's office, as well as my medical group as I didn't think the colonoscopy doctor's office should be paid at all due to their incompetence. Although I did skip complaining to the CA DMC, I gave the doctor's billing department a scathing review on yelp.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Mon Dec 18, 2017 9:20 am

2015 wrote:
Sun Dec 17, 2017 9:17 pm
munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Maybe others have knowledge or views - but with such insurance plans (except for the captive HMOs) isn;t it very unusual that there is no provision whatsoever for out of network providers?

The other part of research is to determine who, how and why this pathologist was used?
Not unusual -- that is exactly the point of an EPO (Exclusive Provider Organization), there is no out of network coverage. If you go out of the EPO network, you are on the hook for all costs. At least, that is my understanding.
Yes, it is an EPO and there is not out of network coverage.

Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.

I do not doubt that I may be on the hook for the entire amount. I am just looking for a validate the charges and mitigate them to the degree possible, if at all.

I also wonder why it was not submitted to the insurance company even if it resulted in a denial. They probably know they are out of network and are possibly just avoiding the paperwork.

Also, I am wondering what I could/should have done to prevent this from happening.
Here's what I did.

As a result of reading threads here regarding these type of surprise billing problems, when signing initial paperwork in my colonoscopy doctor's office I specifically wrote at the bottom (something like) I did not authorize any procedure that was not covered by my insurance company. When I received a $250 bill almost 4 months after the colonoscopy for something like a copay, I protested to the doctor's billing department that this was a surprise bill as I was not informed of any such amount required and had paid my regular specialist copay for the office visit. I kept copious notes of who I spoke to, including date, time of day, and what was said.

Turns out the billing department was highly disorganized, didn't honor any of their promises to either investigate or get back to me, and continued to send me not only bills with $250 copay whatever, but added other charges as well. I complained not only to the insurance carrier, but to the HMO medical group, my PCP's office, and anywhere else I could think of. I threatened to take my case to the CA Dept of Managed Care. This went on for almost 7 months after my January procedure, but concluded with my insurer agreeing to pay the charge to the doctor's office as a "one time courtesy". As a result of their investigation, the additional errant charges were reversed as well. My insurer at the time, Aetna, was surprisingly outstanding at investigating and responding to my escalated complaint.

I did follow up with formal complaints to Aetna, my PCP's office, as well as my medical group as I didn't think the colonoscopy doctor's office should be paid at all due to their incompetence. Although I did skip complaining to the CA DMC, I gave the doctor's billing department a scathing review on yelp.
You sir, have the tenacity of a mongoose!

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Mon Dec 18, 2017 9:29 am

OP here.

Contacted the insurance company using their chat feature this morning. Very helpful. Told her what happened and gave the name of the provider. She said there is coverage. Offered to call the provider for me while I waited. Turns out the billing office was not open yet. Offered to contact them and get back to me. I said "No problem, I can call them myself" which I did.

Provider's billing office did not have my insurance information. I asked how they obtained my name address, phone number, birthday, etc. but not the insurance info. She said..."Hey, we are just a billing office. I work with what we receive." She said to disregard the bill, they will submit and rebill me.

At this point, seems like I made a problem out of nothing. Hopefully it gets processed smoothly from here.

Thanks for those who responded. I did learn some things.

2015
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Re: Health Insurance Out of Network question

Post by 2015 » Tue Dec 19, 2017 10:08 am

munemaker wrote:
Mon Dec 18, 2017 9:20 am
2015 wrote:
Sun Dec 17, 2017 9:17 pm
munemaker wrote:
Sat Dec 16, 2017 9:37 pm
blmarsha123 wrote:
Sat Dec 16, 2017 8:21 pm
dm200 wrote:
Sat Dec 16, 2017 6:30 pm
Just to clarify, I did not GO out of network, as you imply. I was TAKEN out of network, apparently by the in-network surgeon who sent the lab results to this out of network pathologist.

I do not doubt that I may be on the hook for the entire amount. I am just looking for a validate the charges and mitigate them to the degree possible, if at all.

I also wonder why it was not submitted to the insurance company even if it resulted in a denial. They probably know they are out of network and are possibly just avoiding the paperwork.

Also, I am wondering what I could/should have done to prevent this from happening.
Here's what I did.

As a result of reading threads here regarding these type of surprise billing problems, when signing initial paperwork in my colonoscopy doctor's office I specifically wrote at the bottom (something like) I did not authorize any procedure that was not covered by my insurance company. When I received a $250 bill almost 4 months after the colonoscopy for something like a copay, I protested to the doctor's billing department that this was a surprise bill as I was not informed of any such amount required and had paid my regular specialist copay for the office visit. I kept copious notes of who I spoke to, including date, time of day, and what was said.

Turns out the billing department was highly disorganized, didn't honor any of their promises to either investigate or get back to me, and continued to send me not only bills with $250 copay whatever, but added other charges as well. I complained not only to the insurance carrier, but to the HMO medical group, my PCP's office, and anywhere else I could think of. I threatened to take my case to the CA Dept of Managed Care. This went on for almost 7 months after my January procedure, but concluded with my insurer agreeing to pay the charge to the doctor's office as a "one time courtesy". As a result of their investigation, the additional errant charges were reversed as well. My insurer at the time, Aetna, was surprisingly outstanding at investigating and responding to my escalated complaint.

I did follow up with formal complaints to Aetna, my PCP's office, as well as my medical group as I didn't think the colonoscopy doctor's office should be paid at all due to their incompetence. Although I did skip complaining to the CA DMC, I gave the doctor's billing department a scathing review on yelp.
You sir, have the tenacity of a mongoose!
I'm not going to lie, it was a real PIA, but it was the principle of the thing. All I wanted was a simple medical procedure (isn't that what we all want when we go for a service, simplicity and satisfaction?), and the doctor's office ran me around in continuous circles. There was no way I was going to let this go without a fight. To make it easy, I use the same system regardless of issue/vendor screw up by creating a paper/digital trail, taking copious notes regarding statements and promises, including names, title, numbers, etc., taking whatever action is required at the time, and then forgetting about it until the next round in the fight.

I've found that persistence always wins out in the end. Sometimes it's almost excruciating, as I found when devoting hours to figuring out the Rubik's cube of the ACA, almost drowning in the deep end of the pool of tax bracket management, untangling the baffling morass of online, data, financial accounts security, and the mother-of-all PIA's IMO, estate and emergency/disaster planning. My rationale for doing all of this is based on something Dirk Cotton said at The Retirement Cafe: in retirement, you only get "one whack at the cat", only once chance to get it right. If things go wrong for him, he wants it to be because of bad luck, not because he didn't do what was required. I've found if you take care of the little things when--and more importantly before--you have to take care of them, the big things in life will take care of themselves. Just my philosophy, and it's served me well.

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Re: Health Insurance Out of Network question

Post by midareff » Tue Dec 19, 2017 10:12 am

munemaker wrote:
Sat Dec 16, 2017 4:00 pm
My health insurance has very good coverage within a network of providers, but no out of network coverage.

Recently I had a colonoscopy. Prior to the colonoscopy, I called the insurance company if it would be covered and they said yes it would. I asked about the possibility of out of network doctors or anesthesiologists and was told that if the procedure was performed in one of the facilities they cover, the doctors would all be covered...

So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.

I am thinking I need to try to negotiate a reduction with the pathologist. I am sure no insurance company would pay anywhere near the amount I am billed. So how to go about this? Should I call or write? Should I ask for a specific reduction or just ask for a discount? If I am declined, should I try to elevate it?

No experience with this. Any advice would be appreciated.

Thanks
Both my wife and myself have run across this before.... a situation where a provider sends blood or pathology to a provider who is not in network. It is there error and there responsibility to cover the costs of their mistake. When the insurance provider was advised they contacted the institution to advise them it was their responsibility.

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Re: Health Insurance Out of Network question

Post by dm200 » Tue Dec 19, 2017 11:20 am

While not perfect, another reminder of the type of problem we almost never encounter with Kaiser -where the insurer and provider are the same"entity" - so there cannot be a fight between the provider and the insurance company. :happy

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Re: Health Insurance Out of Network question

Post by munemaker » Wed Jan 10, 2018 2:05 pm

dm200 wrote:
Tue Dec 19, 2017 11:20 am
While not perfect, another reminder of the type of problem we almost never encounter with Kaiser -where the insurer and provider are the same"entity" - so there cannot be a fight between the provider and the insurance company. :happy
In this case, the insurer and the provider are the same entity too...University of Pittsburgh Medical Center, aka UPMC. The provider apparently outsourced the pathology.
Last edited by munemaker on Wed Jan 10, 2018 2:09 pm, edited 1 time in total.

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munemaker
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Re: Health Insurance Out of Network question

Post by munemaker » Wed Jan 10, 2018 2:07 pm

midareff wrote:
Tue Dec 19, 2017 10:12 am
munemaker wrote:
Sat Dec 16, 2017 4:00 pm
My health insurance has very good coverage within a network of providers, but no out of network coverage.

Recently I had a colonoscopy. Prior to the colonoscopy, I called the insurance company if it would be covered and they said yes it would. I asked about the possibility of out of network doctors or anesthesiologists and was told that if the procedure was performed in one of the facilities they cover, the doctors would all be covered...

So procedure was performed. Two small polyps were found and removed. Facility fees, doctors fees and anesthesia fees were all covered 100%. There was a $30 in-network lab fee and I was fine with that. Then, after all this, I receive a bill from an out-of-network pathologist I never heard of for $380.

I am thinking I need to try to negotiate a reduction with the pathologist. I am sure no insurance company would pay anywhere near the amount I am billed. So how to go about this? Should I call or write? Should I ask for a specific reduction or just ask for a discount? If I am declined, should I try to elevate it?

No experience with this. Any advice would be appreciated.

Thanks
Both my wife and myself have run across this before.... a situation where a provider sends blood or pathology to a provider who is not in network. It is there error and there responsibility to cover the costs of their mistake. When the insurance provider was advised they contacted the institution to advise them it was their responsibility.
OP here with an update. It has been about 3 weeks since the bill was presented to the insurance company. The online status has shown this as "in process" for that time. I used the online chat feature to inquire about the status today. They told me the claim was flagged as an exception and placed on hold while it is being investigated. That's all they could or would tell me. Will be interesting to see how this shakes out.

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Re: Health Insurance Out of Network question

Post by munemaker » Fri Jan 12, 2018 6:40 am

OP here with final update:

The pathologist claim was finally processed by the insurance company. The pathologist bill was for $380. Insurance paid $340. I pay $0. Presumably he eats the remaining $40.

This pathologist made out a lot better than the anesthesiologist, surgeon and facility, who took sharp discounts on their bills. I am guessing the pathologist was out of network, but since this plan is an EPO and the in-network provider selected the pathologist, it was covered.

This colonoscopy and the associated removal/ biopsy of 2 polyps only cost me $30 (my share of the lab fee). ObamaCare is working out very well for us.

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dm200
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Re: Health Insurance Out of Network question

Post by dm200 » Fri Jan 12, 2018 9:00 am

munemaker wrote:
Fri Jan 12, 2018 6:40 am
OP here with final update:
The pathologist claim was finally processed by the insurance company. The pathologist bill was for $380. Insurance paid $340. I pay $0. Presumably he eats the remaining $40.
This pathologist made out a lot better than the anesthesiologist, surgeon and facility, who took sharp discounts on their bills. I am guessing the pathologist was out of network, but since this plan is an EPO and the in-network provider selected the pathologist, it was covered.
This colonoscopy and the associated removal/ biopsy of 2 polyps only cost me $30 (my share of the lab fee). ObamaCare is working out very well for us.
That's great it worked out so well for you.

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Re: Health Insurance Out of Network question

Post by munemaker » Sun Jan 14, 2018 11:31 am

OP here.

Correction for the record:
Bill was $380. Insurance paid $340. I pay $40.

Previously I said I pay $0. I may have read it wrong (online) but I am pretty sure they changed it (made a correction). EOB shows that the $40 does not count toward co-pay or out of pocket, so that pretty much confirms the Pathologist is out of network. My policy says no out of network coverage, but since this Pathologist was selected by them while I was in their facility, they apparently cover it.

While I have absolutely no problem with paying the $40, I am going to make an inquiry of how the $40/$340 split was determined; not to complain or contest it, only because I like to understand how things work.

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Re: Health Insurance Out of Network question

Post by Ichabob » Mon Jan 15, 2018 8:06 am

Let sleeping dogs lie.

These types of scenarios are why employers sometimes offer this benefit:
http://www.healthadvocate.com/site/prod ... h-advocacy

It's been useful to nag a company to pay up or return phone calls when my nagging proved insufficient.

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dm200
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Re: Health Insurance Out of Network question

Post by dm200 » Mon Jan 15, 2018 10:37 am

Let sleeping dogs lie.
I think so as well.

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