Avoid Health Insurance Traps?

[bailadora]

I don't know if that's the right title to give this thread, but I'm going with it.

So here's the deal: in the last 8 months, I've had to use my insurance benefits more than I've had to in a very long time. And three times, despite my best efforts to avoid it, I've found myself in a situation where I was given care by a non network provider. These were not situations where I made a conscious decision to go out of network. In fact, I did everything I could to remind everyone of what insurance I had, so that I could avoid out of network charges. Didn't happen.

The first case involved me getting an out of network anesthesiologist when I had to have minor surgery in November.

The second case involved my tissue samples going to a non-network lab when I had to have my thyroid biopsied. I had made it a point to remind the receptionist of my insurance provider when the appointment was made. And right after the samples were taken, I inquired about the lab again, in the presence of the doctor. Cue crickets. He has a specific lab he prefers, and the samples had already been placed into their special vials, in their special solution. For reasons I don't quite understand, they could only go to that specific lab. Unless I wanted to lie back down and let him take five more samples. Since I was shaky on my pins from all the nervous dread I'd built up in my mind, I opted out of a second set of samples.

The third case involved tissue samples being sent to the lab at a nearby, in network hospital. But the pathologist who got my samples was, you guessed it, not an in-network provider.

In the first two cases, I was very lucky in that the billing offices agreed to work with me. Acknowledging that I wasn't given a choice to consciously accept or reject the in or out of network status prior to being given the care I received, they agreed to only bill me for what my in network costs would have been.

The last case not so much. Out of network is out of network, and instead of a $300 lab bill, I ended up with one for $900.00. Needless to say, I'm pissed off beyond measure.

It's one thing if I consciously make a choice see a non-network provider, but it's something altogether different to be given care and then informed of status after the fact. Especially when I feel like I've done everything I can to avoid exactly these types of situations. I absolutely LOATHE feeling like I've been backed into a corner and oh by the way, here's your enormous medical bill.

Given that we have Litsters from all different professions here, I'm wondering if anyone who works in medical billing, insurance billing, or hospital administration can share some tips on what the average Joe or Jane can do to avoid ending up in situations like this. It's a huge flaw in our medical system that often leaves people feeling like they got the short end of the stick.

 

[Saucyminx]

Hi Baila,

Before you pay that out of network bill for the lab, call your insurance company and explain the situation. Since you reminded the doc that you needed a specific lab, and they went against your wishes, your insurance company should work as a liaison between the two of you. The devil. . .er I mean, insurance company, I work for, would tell them that we work with a capitated lab, and that they should have to eat that cost--not you, since they know better.

Unless the lab your insurance company mandates doesn't do the test you needed, they shouldn't have sent to an out of network lab. If the lab doesn't do that test, then they should have called ahead to the insurance company to have an out of network authorization done for the test, that way you would only have to pay the difference between what was agreed upon between the insurance network management, and the lab in question.

I would also wonder, how you drew an OON anesthesiologist. Most of them are hospital based, and are paid by the hospital. I would probably have ask the insurance company to check that claim too--to make sure it was billed correctly.

It sounds like the doctor's office totally shit the bed on this whole process.

Call the insurance company and see what they can do for you.

As for avoiding the whole situation, it sounds like you did everything right, that's what really sucks. I would be really raising a ruckus with your Dr. office.

 

[GiggLeGasm]

we avoid a great deal of that here by selecting hospitals who employ the medical care providers as faculty or staff. In the future, it may be something you can ask to assure that anyone who cares for you is an in-network provider. If you are admitted to a hospital who works with private practice physicians, you have little control in who is assigned to you.

Regarding that lab issue.. I would have most certainly requested that they either send the samples to the lab who would be paid by your insurance or reimburse the lab from their own funds. That one, unfortunately, will be hard to argue since you state that they offered a second lab draw. (sucks.. but it is what it is)

for now, you can petition your insurance company to pay all care providers an amount equal to that of an approved provider since they were assigned in situations beyond your control. After that is paid, request a balance adjustment from the care providers with the same reasoning that you provided to the insurance company about your limited ability to select your own care providers.

Both insurance companies and hospitals will have an appeals process and many will be able to assign a financial counselor to assist you. It may be worth looking into that help as well.

Finally...
keep breathing. this will pass. take care of yourself.

 

[bailadora]

With regard to the OON anesthesiologist, one would think if you choose an in-network facility, all of it's employees would, by default, also be in-network providers. Not so much.

When I called the hospital to inquire how this happened, I was informed that all of the anesthesiologists are contract employees. As are all the ER docs and some of the pathologists(God forbid we need emergency care). Apparently, this is becoming more and more common. A friend of mine is a nurse, and she went to work one day, only to find out that unless she was willing to be fired and then rehired as a contract employee, she was out of a job. I guess it's supposed to be a cost saving maneuver for the hospital.

The insurance company, while feeling oh so sorry for me, was less than helpful. They can only pay benefits based upon the provider status. In short, I needed to take this up with the hospital, since they were ones who chose to utilize non-network providers.

The hospital's take is that each individual doc has the right to determine which plans they will and will not accept, so there's not much else they can help me with. If there are issues, I have to take it up with the billing office for that provider.

I was very, very lucky in that the supervisor of the billing office for the anesthesiologist was willing to only bill me at in-network rates. The same thing happened with the lab that got my thyroid tissue samples. I would not let the office send them until I had spoken with the billing supervisor, who agreed to a similar arrangement.

But I'm still stuck with the crazy ass lab bill for the samples that went to the in-network hospital lab. The supervisor at the billing office for the pathologist has been round and round with the insurance company, trying everything she can think of to get them to pay in-network rates. No dice. And her higher ups won't budge on balance billing me for the remaining amount. So with no help from all three offices, I'm SOL. I don't know what else to do.

Part of me wants to say, "Ya know, I'll pay you the in-network rate, and no more, because I wasn't given a choice." But the other part of me is afraid of what might happen if they decide to turn the remaining balance over to collection. Aside from the shitstorm of phone calls I'll get, I'm concerned about how it might affect my credit rating.

Giggle: I wish I had a better selection of hospitals to choose from, but unfortunately for me, there are only three. One of which isn't in my network. And since the other two are run by the same health system, what you get at one is the same as you get at the other location. I could, of course, opt to drive 45 minutes to the next largest city, but that's a helluva long way to drive for nonspecialized medical treatment.

 

[drinkz]

Munky was the first to troll. Query won the war. Putting that much effort into trolling just means you're pathetic in real life.

 

[xanach]

Have you tried just negotiating the price with the lab? My experience has been negotiating with insurance companies is hopeless, but negotiating with providers is usually pretty helpful.

Remember at this point the lab is out whatever the difference is between what they charged and what the insurance company gave them. They have an incentive to negotiate with you now, so they can recoup some of that money.

Collections is a lose lose for both of you, as the lab will get pennies on that sale.

 

[drinkz]

Munky was the first to troll. Query won the war. Putting that much effort into trolling just means you're pathetic in real life.