PPO Coverage Issue

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head gamez
Posts: 112
Joined: Mon Jul 13, 2015 8:30 pm

PPO Coverage Issue

Post by head gamez » Wed Feb 12, 2020 4:31 pm

Back in the second half of 2019 I needed to visit a local ER. We have a handful to choose from so I checked with our PPO website to ensure the one I chose was in network. In and out pretty quickly, no big deal. About 2 months later I got a bill from the Physician Group that works the ER at this Hospital for about $1k. My PPO Co-Pay should be $100 for this type of visit. I called the PPO provider and they informed me that the issue is because the facility is in network but the Physician Group servicing the ER is not. They told me not to worry, they would be in contact with them and get it taken care of. A month later I get another bill (same amount) so I call again. This time I took down the reference number etc so I could easily track the calls etc. I was told that they would take care of it within 4 weeks (given an exact day it would be resolved by) and was given an apology that the previous contact didn't resolve it. Just this week I received another bill and a notice that it was being turned over to collections. When I called the PPO Provider today I was told that they had negotiated it down by about $700 but I would still owe ~$200 more than what my co-pay should be. After some discussion and the person on the phone explaining what had happened to me (as if I didn't already know) and telling me that there was nothing else that could be done, I asked to speak to someone else. The "supervisor" assured me that it would be taken care of and that I just needed to get him the details from the most recent notice. I have his direct extension and will call back tomorrow with that information, but at this point I am not to sure of their ability to resolve this.

Anyone experienced this before? Any recommendations on how I can help get this taken care of in a more timely manner?

FYI... there is nothing on the PPO site about only the facility being in network and requiring me to pay the doctors extra... obviously I would have went to different location had that been communicated.

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Artful Dodger
Posts: 856
Joined: Thu Oct 20, 2016 12:56 pm

Re: PPO Coverage Issue

Post by Artful Dodger » Wed Feb 12, 2020 5:10 pm

head gamez wrote:
Wed Feb 12, 2020 4:31 pm
Back in the second half of 2019 I needed to visit a local ER. We have a handful to choose from so I checked with our PPO website to ensure the one I chose was in network. In and out pretty quickly, no big deal. About 2 months later I got a bill from the Physician Group that works the ER at this Hospital for about $1k. My PPO Co-Pay should be $100 for this type of visit. I called the PPO provider and they informed me that the issue is because the facility is in network but the Physician Group servicing the ER is not. They told me not to worry, they would be in contact with them and get it taken care of. A month later I get another bill (same amount) so I call again. This time I took down the reference number etc so I could easily track the calls etc. I was told that they would take care of it within 4 weeks (given an exact day it would be resolved by) and was given an apology that the previous contact didn't resolve it. Just this week I received another bill and a notice that it was being turned over to collections. When I called the PPO Provider today I was told that they had negotiated it down by about $700 but I would still owe ~$200 more than what my co-pay should be. After some discussion and the person on the phone explaining what had happened to me (as if I didn't already know) and telling me that there was nothing else that could be done, I asked to speak to someone else. The "supervisor" assured me that it would be taken care of and that I just needed to get him the details from the most recent notice. I have his direct extension and will call back tomorrow with that information, but at this point I am not to sure of their ability to resolve this.

Anyone experienced this before? Any recommendations on how I can help get this taken care of in a more timely manner?

FYI... there is nothing on the PPO site about only the facility being in network and requiring me to pay the doctors extra... obviously I would have went to different location had that been communicated.
Most PPO plans are set up to pay non-network providers for emergency care, assuming it was an emergency or needing immediate care diagnosis. Also, some carriers, probably dependent on the locality and local laws, will code non-network docs who provide service at an in-network facility as in-network and pay them the network PPO schedule. Have you checked with the insurance company to see how the claim was processed. It may be the reason the claim was reduced by $700 was the insurance company has paid them the normal fee, and they are balance billing you the difference between their charge and the payment. If they are not contracted, they are not obligated by contract to accept the insurance PPO amount, and will try to collect the difference. My experience has been that most of the time in these situations the provider's finance people will work with the insurer and accept the lower amount, and not ding the patient. BUT, not always. Hopefully, the person you talked to will work it out, and your only charge will be the $100.

So, check with the insurance company to see how it was paid.

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dm200
Posts: 23133
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Location: Washington DC area

Re: PPO Coverage Issue

Post by dm200 » Wed Feb 12, 2020 5:16 pm

We never experienced this issue/challenge, but your narrative seems nearly identical to many others posted here over the years.

One BIG question, then, is what can be done to prevent this problem? In my opinion, this should NOT be YOUR problem, but rather the PPO's problem. I would bet that if you read all of the large and small print of your policy, the PPO should have arranged for such services at your PPO rates and fees.

Please post here what the final result is as well!

quantAndHold
Posts: 3920
Joined: Thu Sep 17, 2015 10:39 pm

Re: PPO Coverage Issue

Post by quantAndHold » Wed Feb 12, 2020 10:24 pm

Basically, your only recourse against balance billing is to live in a state that doesn’t allow it. If you live in a state that allows it, you’re going to get hit sooner or later.


Topic Author
head gamez
Posts: 112
Joined: Mon Jul 13, 2015 8:30 pm

Re: PPO Coverage Issue

Post by head gamez » Fri Feb 21, 2020 4:47 pm

An update. The PPO finally came through and has negotiated this down to $0. Ill keep a check for any additional bills from the provider. I did engage an advocacy group that is provided by my employer, so not sure if that had anything to do with it.

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