Unexpected Medical Bill

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jeam3131
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Unexpected Medical Bill

Post by jeam3131 »

I had a procedure done by a preferred provider under my insurance company, but the provider ended up using a non-preferred anesthesiologist and lab. While the anesthesiologist and lab are still in-network, I ended up getting a large bill because non-preferred services have a separate deductible under my insurance plan.

Any advice about how to navigate this? I feel like it's really unfair because I have no choice in what anesthesiologist or lab the doctor decided to use, but now I'm being asked to pay up.

It seems like my home state has laws against surprise medical billing, but my reading of the law seems to distinguish between nonparticipating and participating provider. In my case, the anesthesiologist and lab are participating, they just arent preferred.
Super Hans
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Re: Unexpected Medical Bill

Post by Super Hans »

I don’t think you’re facing dreaded balance billing. You just have a stingy health plan. Unfortunately, I don’t see a lot of recourse here, unless the plan gives some relief for behind-the-scenes situations like this—like maybe in an emergency context.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Topic Author
jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
Olemiss540
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Re: Unexpected Medical Bill

Post by Olemiss540 »

jeam3131 wrote: Thu Nov 19, 2020 12:03 am
toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
Did you discuss the other service providers with the surgeon and their status as preferred service providers? Sadly I have read enough of these threads to know this is a necessary pre-OP and even that will not ensure the person is there during the actual operation.

Sounds like a pretty stingy healthcare plan having "preffered" in network and "non preferred" in network providers.
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PaunchyPirate
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Re: Unexpected Medical Bill

Post by PaunchyPirate »

Unfortunately, I don't think you have any options except to pay for it. You can try to complain to the insurance company or provider, but this type of thing is permitted in our screwed up country's medical environment.

To prevent this type of thing, you need to ask well before the procedure if all participants will be in-network (and preferred, apparently). And if the Doctor or facility won't guarantee it, then you have the option of going elsewhere or not having it done. Or pay it. In my experience, I can't even get the Doctor or facility to answer the question in writing or provide any sort of guarantee. I get a lot of "They should be..." or "You can call so-and-so to see what they know about it...". It's a mess.

I've never had insurance that had "preferred" and "non-preferred" in-network distinctions. That's pretty lame and if you chose this insurance over competitors, then I would consider leaving them for something better. But you may have to pay more for it. If this is your only insurance option, then so it goes.

This behavior will continue until our government chooses to address the issue (and others).
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hornet96
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Re: Unexpected Medical Bill

Post by hornet96 »

PaunchyPirate wrote: Thu Nov 19, 2020 9:04 am In my experience, I can't even get the Doctor or facility to answer the question in writing or provide any sort of guarantee. I get a lot of "They should be..." or "You can call so-and-so to see what they know about it...". It's a mess.
.....
This behavior will continue until our government chooses to address the issue (and others).
This, exactly. Even if you try to ask in advance and do some due diligence, almost nobody can really answer your questions or make any guarantees. And to find the practices that *maybe* could guarantee all in-network providers, you have to figure out a way to "shop around," which is in-and-of itself a very opaque process to attempt to undertake, even if you have the time and wherewithal to do so.

The doctors will all start chiming in here about the evils of the insurance industry, and how their expertise is in medicine, and they didn't become doctors to become insurance mediators, etc. I certainly respect that; however, these kinds of billing practices would be considered criminal, if they were happening in any other industry.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

Thanks for the responses. I did try calling about the surgery center itself, but no one could answer my question. I even asked for the anesthesia but they blew me off and told me not to worry.
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8foot7
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Re: Unexpected Medical Bill

Post by 8foot7 »

How much money is at stake here?

If it's under $1,000 I'd pay it.

If it's more, that's a more significant discussion and I would be fighting that and perhaps letting it rot for a while and making a settlement offer. I say this because I find these types of bills, from "non-network" doctors who you never meet or see that somehow come in like a ghost in the middle of the night in the middle of a procedure at an "in-network" office with an "in-network" doctor who you do know, about as close to legal fraud as you can get.

If these folks want to post their prices and who's coming in in public for all to see and agree to beforehand, then one wouldn't have a leg to stand on and all amounts billed should be paid. But as long as people who I've never met who I didn't ask for get to come in to a situation where I'm unconscious and then send me large bills for their expertise that I didn't previously agree to or know was happening, I'm going to question and beat down those bills if they're excessive.
Big Dog
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Re: Unexpected Medical Bill

Post by Big Dog »

jeam3131 wrote: Thu Nov 19, 2020 9:58 am Thanks for the responses. I did try calling about the surgery center itself, but no one could answer my question. I even asked for the anesthesia but they blew me off and told me not to worry.
Unfortunately, you are probably stuck. In the future, tell the doc that unless the sugi-center's staff are all in network preferred, you'd prefer another facility. (The doc may/likely has a financial interest in the surgi-center.) For example, when i had to have an outpatient procedure, the Ortho said up front, "I can get you into the surgi-center up the street this week where I am a partner, or we can schedule you at the hospital next week." My response, "Your center is fine, as long as all staff and any other providers are in network." Doc: "I understand, and I'll have the Center double check with your insurance". And he did, and they did.
runninginvestor
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Re: Unexpected Medical Bill

Post by runninginvestor »

As others have noted, this is one of those grey areas. Balance/surprise billing has been passed, but it probably has a gap for preferred/non-preferred payment arrangements. Medicare has a similar hiccup with assignment vs non-assignment.

Best bet would be to appeal to insurance to get it covered at the preferred rate. Either case, look into filing a complaint with the state insurance commissioner to add yourself to the growing number of people hopefully speaking up about these things.
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JoeRetire
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Re: Unexpected Medical Bill

Post by JoeRetire »

jeam3131 wrote: Wed Nov 18, 2020 8:12 pm I had a procedure done by a preferred provider under my insurance company, but the provider ended up using a non-preferred anesthesiologist and lab. While the anesthesiologist and lab are still in-network, I ended up getting a large bill because non-preferred services have a separate deductible under my insurance plan.

Any advice about how to navigate this?
Knowing that non-preferred anesthesiologists/labs have a separate deductible, it's incumbent on you to ask up front which anesthesiologists/labs will be used, talk with your insurance company to see if they are on the preferred list or not, and then make your go/no go decision accordingly.

It may not feel fair, but it is what it is.
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quantAndHold
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Re: Unexpected Medical Bill

Post by quantAndHold »

Does your state have laws about balance billing?

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snowman
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Re: Unexpected Medical Bill

Post by snowman »

I feel for you, OP. This has been going on for many, many years. Since we are well aware of the practice, my wife made numerous phone calls last year before my surgery, to make sure it does not happen to us. I said there is no way I am doing it unless I am 100% sure everyone, including anesthesiologist, is in network.

First time around, the answer was no. Later, answer changed to yes, all in network. Great, can I get that in writing? Oops, so the anesthesiology group is in network, but not every doctor inside the group is part of the contract. OK, can you give me names of those that are, to make sure I don't get OON bill? No, we cannot, and even if we did, there is no guarantee WHO you actually meet on the day of surgery. Talk about buying cat in the bag!

I would definitely fight the bill with insurance company. I am not saying you will succeed, but if you can document to them you made phone calls ahead of time to make sure it doesn't happen, they may cut the bill for you.

I really hate this medical billing practice, really surprised it's still being considered legal.
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Kenkat
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Re: Unexpected Medical Bill

Post by Kenkat »

My plan has a lower deductible for preferred in-network providers and “regular” network providers but the difference is only $500 and it’s really offered as an additional benefit - i.e. the in-network deductible is $5500 but if you use preferred, it is $5000. If I have a claim for a non-preferred network provider, it still counts towards both deductibles - they are not separate. Maybe your plan is different but it seems strange to me that you’d have a large bill from this.

So - I’d call your insurance company and make sure everything was applied correctly to the deductibles and that it’s clear how it is all supposed to work. I’d also be sure that the provider is billing you for the negotiated network rate after deductible is accounted for.
JackoC
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Re: Unexpected Medical Bill

Post by JackoC »

quantAndHold wrote: Thu Nov 19, 2020 11:14 am Does your state have laws about balance billing?
OP's issue seems to be different than classic 'balance billing' by out-of-network providers. It seems to be a plan which has materially different coverage for different *in network* providers. A plan I had till last year (in NJ) had a nominal difference in 'tier' of in-network provider but the coverage wasn't actually materially different between the two tiers. As usual, I'd find health insurance threads here more useful if people would just say which state they are in and actual amounts. I could understand withholding pertinent info like that if say on Facebook with your real name, with screen names I don't really get it. But it's a free internet (by and large) so whatever.

In NJ there's now a strong balance billing law v out of network charges. The insurers are still AFAIK allowed to have 'tiers' in-network, though my current provider doesn't have that, and as I said with the previous one the actual $ coverage difference between tiers was not big, not any difference in the deductible IIRC.
DarkHelmetII
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Re: Unexpected Medical Bill

Post by DarkHelmetII »

jeam3131 wrote: Wed Nov 18, 2020 8:12 pm I had a procedure done by a preferred provider under my insurance company, but the provider ended up using a non-preferred anesthesiologist and lab. While the anesthesiologist and lab are still in-network, I ended up getting a large bill because non-preferred services have a separate deductible under my insurance plan.

Any advice about how to navigate this? I feel like it's really unfair because I have no choice in what anesthesiologist or lab the doctor decided to use, but now I'm being asked to pay up.

It seems like my home state has laws against surprise medical billing, but my reading of the law seems to distinguish between nonparticipating and participating provider. In my case, the anesthesiologist and lab are participating, they just arent preferred.
Offer the anesthesiologist and lab what would be owed if they had been preferred. Make sure there is a record of this offer. Perhaps even pay it (if you still would owe some $$). Also, to the extent that you have it, shore up any documentation on due diligence you performed to ensure the provider was preferred. In order to collect they ultimately have to convince the courts in which case you have your documentation.

This is just one option. I have no idea if we're talking $200 or $20,000. Or how much time you have to spend on this. But the point is that it sounds as though a cogent argument can be made that a "reasonable person" would expect that selecting the provider is within your control but ensuring that the anesthesiologist and lab are outside of your control and you should not be penalized as such.
Last edited by DarkHelmetII on Thu Nov 19, 2020 4:47 pm, edited 1 time in total.
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hornet96
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Re: Unexpected Medical Bill

Post by hornet96 »

JoeRetire wrote: Thu Nov 19, 2020 10:58 am
Knowing that non-preferred anesthesiologists/labs have a separate deductible, it's incumbent on you to ask up front which anesthesiologists/labs will be used, talk with your insurance company to see if they are on the preferred list or not, and then make your go/no go decision accordingly.

It may not feel fair, but it is what it is.
Maybe you missed the OP's follow up:
jeam3131 wrote: Thu Nov 19, 2020 9:58 am Thanks for the responses. I did try calling about the surgery center itself, but no one could answer my question. I even asked for the anesthesia but they blew me off and told me not to worry.
The problem isn't that the OP didn't try to ask, the problem is that health care providers and insurance companies can't or won't answer the questions being asked - and then expect you to pay the huge bill they send you afterward, when the provider unilaterally decides to use an out-of-network / non-preferred doctor.
GlacierRunner
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Re: Unexpected Medical Bill

Post by GlacierRunner »

Is this a self-funded plan or is it an insured plan? If it is insured, you might reach out to your state department of insurance.
The recommendation to look for state balance bill protection is a good one. If your state isn't listed in the referenced article, you still might want to reach out to the DOI. My state is not listed as having balance bill protection, but we do have a separate requirement that if you did not select the provider, that the health care insurer must reimburse at the in-network level of cost sharing (deductible, coinsurance). You still may have a balance bill in this situation, but the cost sharing on your part would be lower.

In addition, review your plan for language such as "if you don't select", "If you have no choice" etc. to see if you have any contract language providing you protection in this case.
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Nate79
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Re: Unexpected Medical Bill

Post by Nate79 »

Did you talk to your insurance company?
quantAndHold
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Re: Unexpected Medical Bill

Post by quantAndHold »

JackoC wrote: Thu Nov 19, 2020 12:48 pm
quantAndHold wrote: Thu Nov 19, 2020 11:14 am Does your state have laws about balance billing?
OP's issue seems to be different than classic 'balance billing' by out-of-network providers. It seems to be a plan which has materially different coverage for different *in network* providers.
That is one of the forms that balance billing takes. Some states have protections, many don't. It's good to know which you live in.
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Topic Author
jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

quantAndHold wrote: Thu Nov 19, 2020 4:03 pm
JackoC wrote: Thu Nov 19, 2020 12:48 pm
quantAndHold wrote: Thu Nov 19, 2020 11:14 am Does your state have laws about balance billing?
OP's issue seems to be different than classic 'balance billing' by out-of-network providers. It seems to be a plan which has materially different coverage for different *in network* providers.
That is one of the forms that balance billing takes. Some states have protections, many don't. It's good to know which you live in.
Michigan. They just passed a law that protects patients on this, but the distinction is between participating and nonparticipating provider. This particular issue is with a participating but not preferred provider.
trueblueky
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Re: Unexpected Medical Bill

Post by trueblueky »

We have found it impossible to get assurance that the anesthesiologist would be in plan. BCBS Federal has been understanding of that issue and covered enough that the excess billing went away.

We have also had problems at hospitals. "I only want to see people who are in plan." Ok. "Please put that on my charts." Ok. We wrote it on the white board in our room that everyone should reference. We still received a bill from an out-of-plan hospitalist.

Deleted insult.
Last edited by trueblueky on Fri Nov 20, 2020 12:12 am, edited 1 time in total.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

PaunchyPirate wrote: Thu Nov 19, 2020 9:04 am

I've never had insurance that had "preferred" and "non-preferred" in-network distinctions. That's pretty lame and if you chose this insurance over competitors, then I would consider leaving them for something better. But you may have to pay more for it. If this is your only insurance option, then so it goes.
I have never heard of this either. You were given in-network providers, but did you request specifically "preferred" providers? I doubt your surgeon even knows your plan has different tiers.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

trueblueky wrote: Thu Nov 19, 2020 5:52 pm We have found it impossible to get assurance that the anesthesiologist would be in plan. BCBS Federal has been understanding of that issue and covered enough that the excess billing went away.

We have also had problems at hospitals. "I only want to see people who are in plan." Ok. "Please put that on my charts." Ok. We wrote it on the white board in our room that everyone should reference. We still received a bill from an out-of-plan hospitalist.

Bottom feeders.
How would the hospitalist know if he/she is in-network with your specific plan? This is governed by their employer.
prioritarian
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Re: Unexpected Medical Bill

Post by prioritarian »

One way to avoid this issue is to insure with a large non-profit HMO.
Broken Man 1999
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Re: Unexpected Medical Bill

Post by Broken Man 1999 »

I have used HMOs and PPOs for years and the only time I have seen "preferred providers" was in pharmacy prices.

I am incented to buy 90 day mail order drugs or my co-pay for a month's supply is the same as the mail order 3 month supply.

One exception: my narcotics. Used to be I could get 90 days with zero co-pay. Now I can only get a month's worth with a $10_copay. Since the price is the same, I now buy my pain killers at Publix for the same co-pay as mail order.

So, Humana used the opiod scare to increase my yearly co-pay from $0 to $120. I saw no reason to reward Humana for that slight of hand.

So far a preferred or not preferred medical services, never encountered that at all. If the provider was in network, there was no preferred or not preferred difference.

Broken Man 1999
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toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

prioritarian wrote: Fri Nov 20, 2020 3:41 pm One way to avoid this issue is to insure with a large non-profit HMO.
Why non-profit?
prioritarian
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Re: Unexpected Medical Bill

Post by prioritarian »

toofache32 wrote: Fri Nov 20, 2020 7:56 pm
prioritarian wrote: Fri Nov 20, 2020 3:41 pm One way to avoid this issue is to insure with a large non-profit HMO.
Why non-profit?
Because the three large non-profit HMOs I'm familiar with all tend to use in-house physicians wherever possible and when they do not provide exceptions. I'm unfamiliar with large for-profit HMOs because there aren't any where I live.
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Chrono Triggered
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Re: Unexpected Medical Bill

Post by Chrono Triggered »

I would call up the billing department, explain your end of it in a calm manner, and ask for the bill to be reduced or dropped entirely. Medical bills can often be haggled.
Gabelli2020
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Re: Unexpected Medical Bill

Post by Gabelli2020 »

I’m a retired surgeon, and have been on the receiving end of this scenario- especially pathologists who are either out of network or non - preferred. It stinks. The system stinks. We physicians were, and are, a huge part of the problem. I usually argue with the billing department, and then offer a cash ( credit card) settlement pronto. I’ve gotten no discount all the way to 90% off.
Northern Flicker
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Re: Unexpected Medical Bill

Post by Northern Flicker »

jeam3131 wrote: Thu Nov 19, 2020 12:03 am
toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
The anasthesiologist and lab probably had no say in the selection either, so I don't see why they should be stiffed.

But you did have say in the choice. Did you raise the issue of needing services on the preferred list a priori? If not, this is your issue 100%.

Perhaps the physician who selected the services even went the extra mile to confirm providers were in-network, but had no way of knowing that was an incomplete criterion.

Pay the bill.
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Picasso
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Re: Unexpected Medical Bill

Post by Picasso »

Sorry that your different providers were included on different tiering and this hit separate deductible accumulators.

Not a balance billing issue and the recent spat of current legislation being passed in various states (balance billing, OON emergency coverage, etc) don’t aim to address this.

Pay the bill and be done with it.
InMyDreams
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Re: Unexpected Medical Bill

Post by InMyDreams »

Gabelli2020 wrote: Sat Nov 21, 2020 5:03 pm ...have been on the receiving end of this scenario- especially pathologists who are either out of network or non - preferred. It stinks. The system stinks.
+1
JPM
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Re: Unexpected Medical Bill

Post by JPM »

Surgeons, when they can choose the anesthesiologist at all, choose based on clinical ability. More often daily assignments within the anesthesia department are made by the service chief with the patients at higher risk of complications are assigned to the anesthesia provider believed to be most able to handle the foreseeable complications. Insurance considerations generally do not enter into these decisions. The surgeon generally has no way of knowing what insurance arrangements an anesthesiologist might have with any of the hundreds of insurance plans they would be contracted with let alone the arrangements with OP's particular plan. A given anesthesiologist may be in-network with some Blue Cross plans and out of network with others. The nature of this arrangement will often lead to problems such as described by the OP.

If the anesthesiologist is employed by the hospital, he/she will generally be in-network when the hospital is in-network. If the anesthesiologist is employed by the surgicenter as an employee, same thing. If the anesthesiologist is an independent contractor or working at the surgicenter or hospital as part of a contracted group that has contracted with the hospital or surgicenter to provide anesthesia services, then anesthesia contracts with insurers will be separate from the contract with the hospital or surgicenter. The hospital or surgicenter may or may not require their anesthesiology service to accept in-network fees depending on the local market for anesthesia services.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

jeam3131 wrote: Thu Nov 19, 2020 12:03 am
toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
jeam3131 wrote: Thu Nov 19, 2020 9:58 am Thanks for the responses. I did try calling about the surgery center itself, but no one could answer my question. I even asked for the anesthesia but they blew me off and told me not to worry.

So which is it? Is it the physician's office? Or a surgery center? The real question I am asking is why aren't you asking the boss about this instead of the doctor? When the airline loses your baggage, do you complain to the pilot?

Most people still think the doctors are in charge these days. I am a doctor working 2 days a week in an employed hospital setting. It's amazing what patients complain to me about as if I have some control. A patient told me "Nurse Becky who checked me in was very rude." I said "Yes I agree Becky is rude. Tell me what brings you in today."
Kagord
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Re: Unexpected Medical Bill

Post by Kagord »

jeam3131 wrote: Thu Nov 19, 2020 4:36 pm
quantAndHold wrote: Thu Nov 19, 2020 4:03 pm
JackoC wrote: Thu Nov 19, 2020 12:48 pm
quantAndHold wrote: Thu Nov 19, 2020 11:14 am Does your state have laws about balance billing?
OP's issue seems to be different than classic 'balance billing' by out-of-network providers. It seems to be a plan which has materially different coverage for different *in network* providers.
That is one of the forms that balance billing takes. Some states have protections, many don't. It's good to know which you live in.
Michigan. They just passed a law that protects patients on this, but the distinction is between participating and nonparticipating provider. This particular issue is with a participating but not preferred provider.
Is your plan self insured that is administered and managed by an insurance company? Sometimes, state laws do not apply to the self insured plans, and most big companies are self insured.
clip651
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Re: Unexpected Medical Bill

Post by clip651 »

toofache32 wrote: Sat Nov 21, 2020 10:17 pm The real question I am asking is why aren't you asking the boss about this instead of the doctor? When the airline loses your baggage, do you complain to the pilot?

Most people still think the doctors are in charge these days. I am a doctor working 2 days a week in an employed hospital setting. It's amazing what patients complain to me about as if I have some control. A patient told me "Nurse Becky who checked me in was very rude." I said "Yes I agree Becky is rude. Tell me what brings you in today."
If you want us to ask the boss, and not the pilot, you want us to call the CEO of the airline about the lost luggage? That's what calling the boss would look like there, I don't think that's what you mean ...

Patients often have no idea who is in charge. The doctor is the highest ranking person in the office (at least as far as the patient knows) that they come into speaking contact with.

If you want patients to know who to complain to, talk to your boss and have him/her hand us a pamplet on the way in, explaining the structure of the practice, who makes what decisions, and where various questions and complaints should go.

For example, I've been going to a specialist for years. I know there are multiple other specialists in the group that work out of the same office. Are they all partners? Three partners, with varying seniority, and some underlings? Is one employing the others? Are they all working for some corporation and answer to an office manager? How in the world would I know?? (And ditto for all the other doctor's offices I deal with in the course of a year.)

I don't know, but I do expect my doctor to be able to tell me how to navigate their system. He/she orders a test - who do I call to get results, or do you call me? A procedure is ordered - who do I check in with to see if my insurance has approved it (I know enough to know that they will seek pre-approval), what is the process for getting on the schedule? Etc. If the doctor can't answer those questions, they need to at least be able to point me to the person who can. Please don't blame the victims, er, patients, for the crazy mess we have to deal with to get care.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

clip651 wrote: Sat Nov 21, 2020 11:02 pm
toofache32 wrote: Sat Nov 21, 2020 10:17 pm The real question I am asking is why aren't you asking the boss about this instead of the doctor? When the airline loses your baggage, do you complain to the pilot?

Most people still think the doctors are in charge these days. I am a doctor working 2 days a week in an employed hospital setting. It's amazing what patients complain to me about as if I have some control. A patient told me "Nurse Becky who checked me in was very rude." I said "Yes I agree Becky is rude. Tell me what brings you in today."
If you want us to ask the boss, and not the pilot, you want us to call the CEO of the airline about the lost luggage? That's what calling the boss would look like there, I don't think that's what you mean ...

Patients often have no idea who is in charge. The doctor is the highest ranking person in the office (at least as far as the patient knows) that they come into speaking contact with.

If you want patients to know who to complain to, talk to your boss and have him/her hand us a pamplet on the way in, explaining the structure of the practice, who makes what decisions, and where various questions and complaints should go.

For example, I've been going to a specialist for years. I know there are multiple other specialists in the group that work out of the same office. Are they all partners? Three partners, with varying seniority, and some underlings? Is one employing the others? Are they all working for some corporation and answer to an office manager? How in the world would I know?? (And ditto for all the other doctor's offices I deal with in the course of a year.)

I don't know, but I do expect my doctor to be able to tell me how to navigate their system. He/she orders a test - who do I call to get results, or do you call me? A procedure is ordered - who do I check in with to see if my insurance has approved it (I know enough to know that they will seek pre-approval), what is the process for getting on the schedule? Etc. If the doctor can't answer those questions, they need to at least be able to point me to the person who can. Please don't blame the victims, er, patients, for the crazy mess we have to deal with to get care.
Thank you for proving my point. Everyone thinks the doctor is the boss when actually he/she is just an employee like the lady at the front desk. Tell me your medical symptoms, but don't waste my time with business complaints. Just like you wouldn't waste the front desk lady's time asking her why your stomach hurts. It's not hard to ask who the supervisor is.

As far as the OP, he has a crummy plan and is trying to make it someone else's problem. All providers are billing based on that plan's rules he agreed to. If you know your plan has preferred providers, you should make every effort to request preferred providers.
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celia
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Re: Unexpected Medical Bill

Post by celia »

I would file an APPEAL with your insurance company. I did this once and explained how I didn’t have any “say” on who the in-/out-of-network providers would be.

When you get to the insurance claims department to request this, the agent will likely be able to write up the appeal with you on the phone. Have them read back the text before you let them “submit” it so it sounds complete to you. The agent will know what to say so the appeal’s committee will understand and possibly grant your appeal.
fsrph
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Re: Unexpected Medical Bill

Post by fsrph »

JPM wrote: Sat Nov 21, 2020 7:47 pmIf the anesthesiologist is an independent contractor or working at the surgicenter or hospital as part of a contracted group that has contracted with the hospital or surgicenter to provide anesthesia services, then anesthesia contracts with insurers will be separate from the contract with the hospital or surgicenter. The hospital or surgicenter may or may not require their anesthesiology service to accept in-network fees depending on the local market for anesthesia services.
And this is where the problem is. All I see in my area is anesthesia groups signing contracts with hospitals. After the contract is signed there is no need to be in network (unless it's in the contract to do so). So, hospitals share in having out of network anesthesiologists as they did not require being in network in the contract. To the public this is so confusing, especially since you have no choice in selecting the anesthesiologist.

Francis
"Success is getting what you want. Happiness is wanting what you get." | Dale Carnegie
oldfort
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Re: Unexpected Medical Bill

Post by oldfort »

toofache32 wrote: Sat Nov 21, 2020 11:20 pm If you know your plan has preferred providers, you should make every effort to request preferred providers.
Does the patient have any control over who their anesthesiologist is?
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

fsrph wrote: Sun Nov 22, 2020 12:21 am
JPM wrote: Sat Nov 21, 2020 7:47 pmIf the anesthesiologist is an independent contractor or working at the surgicenter or hospital as part of a contracted group that has contracted with the hospital or surgicenter to provide anesthesia services, then anesthesia contracts with insurers will be separate from the contract with the hospital or surgicenter. The hospital or surgicenter may or may not require their anesthesiology service to accept in-network fees depending on the local market for anesthesia services.
And this is where the problem is. All I see in my area is anesthesia groups signing contracts with hospitals. After the contract is signed there is no need to be in network (unless it's in the contract to do so). So, hospitals share in having out of network anesthesiologists as they did not require being in network in the contract. To the public this is so confusing, especially since you have no choice in selecting the anesthesiologist.

Francis
Similarly, those anesthesiologists have no choice in selecting their patients. They are in-network with insurance companies that pay competitive rates. If your insurance refuses to pay competitive rates then the anesthesiologists cannot be faulted for that.
toofache32
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Re: Unexpected Medical Bill

Post by toofache32 »

oldfort wrote: Sun Nov 22, 2020 12:27 am
toofache32 wrote: Sat Nov 21, 2020 11:20 pm If you know your plan has preferred providers, you should make every effort to request preferred providers.
Does the patient have any control over who their anesthesiologist is?
For scheduled surgery, yes. Ask them if they are whatever you want them to be. If not, ask your insurance company for "preferred" options.
Patients have the same choices as anesthesiologists when everyone signs up for someone else to pay for it.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

toofache32 wrote: Sat Nov 21, 2020 10:17 pm
jeam3131 wrote: Thu Nov 19, 2020 12:03 am
toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
jeam3131 wrote: Thu Nov 19, 2020 9:58 am Thanks for the responses. I did try calling about the surgery center itself, but no one could answer my question. I even asked for the anesthesia but they blew me off and told me not to worry.

So which is it? Is it the physician's office? Or a surgery center? The real question I am asking is why aren't you asking the boss about this instead of the doctor? When the airline loses your baggage, do you complain to the pilot?

Most people still think the doctors are in charge these days. I am a doctor working 2 days a week in an employed hospital setting. It's amazing what patients complain to me about as if I have some control. A patient told me "Nurse Becky who checked me in was very rude." I said "Yes I agree Becky is rude. Tell me what brings you in today."
The doctor's office was the surgery center. And as a doctor, many if not most patients view you as having captain of the ship responsibility. That's just how it is, you can't change that. And I hope you in your example aren't throwing your nurse under the bus. It would be much more productive to tell the patient you're sorry for their experience and tell them you'll speak to the nurse, and then do so. How people feel when they visit your practice ends up being a reflection on how they feel about you, even the components you don't control.

And for the record, I never once blamed the physician here.
Last edited by jeam3131 on Sun Nov 22, 2020 6:28 am, edited 3 times in total.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

toofache32 wrote: Sat Nov 21, 2020 11:20 pm
clip651 wrote: Sat Nov 21, 2020 11:02 pm
toofache32 wrote: Sat Nov 21, 2020 10:17 pm The real question I am asking is why aren't you asking the boss about this instead of the doctor? When the airline loses your baggage, do you complain to the pilot?

Most people still think the doctors are in charge these days. I am a doctor working 2 days a week in an employed hospital setting. It's amazing what patients complain to me about as if I have some control. A patient told me "Nurse Becky who checked me in was very rude." I said "Yes I agree Becky is rude. Tell me what brings you in today."
If you want us to ask the boss, and not the pilot, you want us to call the CEO of the airline about the lost luggage? That's what calling the boss would look like there, I don't think that's what you mean ...

Patients often have no idea who is in charge. The doctor is the highest ranking person in the office (at least as far as the patient knows) that they come into speaking contact with.

If you want patients to know who to complain to, talk to your boss and have him/her hand us a pamplet on the way in, explaining the structure of the practice, who makes what decisions, and where various questions and complaints should go.

For example, I've been going to a specialist for years. I know there are multiple other specialists in the group that work out of the same office. Are they all partners? Three partners, with varying seniority, and some underlings? Is one employing the others? Are they all working for some corporation and answer to an office manager? How in the world would I know?? (And ditto for all the other doctor's offices I deal with in the course of a year.)

I don't know, but I do expect my doctor to be able to tell me how to navigate their system. He/she orders a test - who do I call to get results, or do you call me? A procedure is ordered - who do I check in with to see if my insurance has approved it (I know enough to know that they will seek pre-approval), what is the process for getting on the schedule? Etc. If the doctor can't answer those questions, they need to at least be able to point me to the person who can. Please don't blame the victims, er, patients, for the crazy mess we have to deal with to get care.
Thank you for proving my point. Everyone thinks the doctor is the boss when actually he/she is just an employee like the lady at the front desk. Tell me your medical symptoms, but don't waste my time with business complaints. Just like you wouldn't waste the front desk lady's time asking her why your stomach hurts. It's not hard to ask who the supervisor is.

As far as the OP, he has a crummy plan and is trying to make it someone else's problem. All providers are billing based on that plan's rules he agreed to. If you know your plan has preferred providers, you should make every effort to request preferred providers.
Make it someone else's problem? I did attempt to do this, but was stonewalled by the office staff. Hopefully this situation doesn't happen to you because navigating this from the patient perspective is not easy. If you look at my insurance companies website, it clearly lists the office I had the procedure done as preferred. Any reasonable person would assume this means the procedure would be performed with preferred level coverage, not receive multiple bills with some being preferred and some not. And the expectation for patients to be able to navigate that isn't really consumer friendly. I'll tell you, many people do NOT have the capability to navigate all that. I don't see any other industry where you could get away with something like this.

Thanks to everyone who has provided advice. I wasn't looking to be blamed for this issue, that's not really constructive. I just wanted to see if anyone went through a similar situation.
Last edited by jeam3131 on Sun Nov 22, 2020 6:18 am, edited 3 times in total.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

toofache32 wrote: Sun Nov 22, 2020 12:30 am
oldfort wrote: Sun Nov 22, 2020 12:27 am
toofache32 wrote: Sat Nov 21, 2020 11:20 pm If you know your plan has preferred providers, you should make every effort to request preferred providers.
Does the patient have any control over who their anesthesiologist is?
For scheduled surgery, yes. Ask them if they are whatever you want them to be. If not, ask your insurance company for "preferred" options.
Patients have the same choices as anesthesiologists when everyone signs up for someone else to pay for it.
There was no choice. This is who they contracted with.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

celia wrote: Sun Nov 22, 2020 12:16 am I would file an APPEAL with your insurance company. I did this once and explained how I didn’t have any “say” on who the in-/out-of-network providers would be.

When you get to the insurance claims department to request this, the agent will likely be able to write up the appeal with you on the phone. Have them read back the text before you let them “submit” it so it sounds complete to you. The agent will know what to say so the appeal’s committee will understand and possibly grant your appeal.

Yes, I am in the process of this. Thanks for the advice and the tip on having them read it back. I've run into issues before with other things where the rep did a poor job typing up the report.
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jeam3131
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Re: Unexpected Medical Bill

Post by jeam3131 »

Northern Flicker wrote: Sat Nov 21, 2020 5:15 pm
jeam3131 wrote: Thu Nov 19, 2020 12:03 am
toofache32 wrote: Wed Nov 18, 2020 11:57 pm What makes you think the surgeon chose the anesthesiologist and lab? Was this in a hospital?
Outpatient procedure performed in the in-network physicians office. I had no say or knowledge of what anesthesiologist or lab that would be chosen. That's all done behind the scenes
The anasthesiologist and lab probably had no say in the selection either, so I don't see why they should be stiffed.

But you did have say in the choice. Did you raise the issue of needing services on the preferred list a priori? If not, this is your issue 100%.

Perhaps the physician who selected the services even went the extra mile to confirm providers were in-network, but had no way of knowing that was an incomplete criterion.

Pay the bill.
Although not my exact situarion, many states now have laws against this type of billing. Any ancillary services that bill separately have to provide a patient with at least 14 days notice they may be out of network and they must provide a good faith estimate of the cost. Failure to do so means the service must negotiate pay with the insurance company directly and not involve the patient.
musicmom
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Re: Unexpected Medical Bill

Post by musicmom »

OP, I feel for you.
Im recently retired and have resigned myself that my new almost fulltime job is working through the numerous issues of medical billing for myself, husband and disabled adult child.
And we each have different insurance coverage including commercial retiree, Medicare and Medicaid.

Ive decided to weigh the value of each issue.
A bill I receive for $16.97 that should have been paid by secondary insurer I wont fight. Just not worth the time.
The $1500 bill for private hospital room I had no choice in (room availability) I appealed and won. Urgent care center processed out of network in error. ER visit denied as "non emergency use of ER" appealed and won.

My main insurer has an appeal form attached to each paper EOB. Short and simple.
Always keep copy.
Ive found it more effective than to chance confusion with phone rep hearing things incorrectly.

I so wish it wasnt this way. Maybe someday it will be easier for patients.
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