Help a Reader: Medical Billing Problem

Here's an email I recently received from a reader:

At 23 years old, I recently had knee problems and went to an orthopedic practice for diagnosis. When I called for an appointment I was asked what insurance I had, and was given an appointment with and saw a doctor who was covered under my insurance - as would be expected. This doctor diagnosed a knee issue requiring surgery, and referred me to another doctor at the same practice. Thinking nothing of it, I saw that doctor once in the office, followed by his performing my surgery.

The day I get back from the hospital (4/22), I see in the mail a letter delivered that day, but dated 4/16, stating that I am approved for outpatient surgery using an out-of-network doctor. A couple of days later I get a $250 bill for my initial visit with the surgeon, not covered by insurance. Bear in mind that I've already had a followup appointment with him where he just said "Good job, keep icing it!," that I'll probably receive a similar $250 bill for. I have another followup appointment with him scheduled for June.

Fortunately, I saw a $6,000 hospital facility / lab fee post to my insurance, covered at 100%, but after digging for a couple of minutes I'm pretty certain that the surgeon and anesthesiologist are not in-network under my insurance. My out-of-network coverage has a $3,000 deductible that I of course don't want to contribute to, and while I understand that it was likely my technical responsibility to ensure that everyone involved was covered under my insurance, it is disturbing that an in-network physician in an orthopedic practice would refer me to an out-of-network surgeon in that same practice without anyone mentioning anything.

Any suggestions as to how I can best resolve this? (With the doctor(s)? With the insurance company? Both?) As a related aside, I have a very good rapport with the surgeon. Thank you!

Any suggestions for him?

Comments

[toughluck]

[Comment deleted due to vulgarity.]

FMF

[byhec]

DITTO

[indio]

Thank was incredibly unhelpful advice by the previous posters.
I consulted with a specialist that was referred to me by another doctor. When I found out that the doc was out of network, I asked the front desk to find out if he would be willing to see me at a reduced fee. There are still some sympathetic docs out there that feel the insurance companies are doing a disservice to both medical practitioner and patient. Ask to speak to doc or send letter explaining the problem and wait to see what they offer. Keep a $ amount in mind that you would find acceptable, but don't throw it out there till you see what they are willing to offer.

[Marilyn]

I would appeal with the insurance company based on the position that an in-network provider directed your treatment to an out-of-network surgeon. Request documentation from your in-network provider explaining why your care was referred to this specific surgeon. Based on this information, perhaps your claim could be reconsiderated.

[Kate]

This may sound remarkably silly but you may want to take a step back and make sure that the surgeon you dealt with is really not a provider. Many times there are simple coding errors. If that does not work I would see if it was possible to talk with both the doctor who performed the procedure AND the physician who referred you. It's possible that they may be able to either work some kind of billing miracle, or at least help negotiate something you can do. In the meantime make some kind of minimal "good faith" payment monthly. In most cases the billing is done out of the office and will have no idea of anything that you are dealing with inside the office. Good luck!

[Hickepedia]

It's still the patient's responsibility to ensure that when a referral is given, that it's to a provider that takes your insurance. The whole reason for having a network of providers is that your insurance provider has already negotiated rates for medical procedures with them. The time to talk to your insurance company about using non-network providers is before you get procedures done.

Always make sure that the claim was filed and processed correctly, but the odds aren't on your side. The doctor's office and the claims processors at your insurance company do the claims filing and processing thing for a living (and are usually measured on their accuracy as a performance metric), and don't often make mistakes.

Unfortunately, you're likely to wind up filling in some or all of that $3,000 deductible before you're done paying those bills. Make payment arrangements with the surgeon's and anesthesiologist's offices when the bills come in. They don't like having to dun you any more than you like getting dunned.

[Denise]

I'm sure this is stressful for you. I would encourage you to contact both the medical office billing and the insurance company. I would contact the medical office billing first and politely explain that you misunderstood and believed the surgeon was in network. The medical office could choose to write off a portion of your bill. I don't understand it but my dentist office does this. They have some providers on the insurance panel and others they aren't. If you see one of the others the billing department writes off the difference between the billed rate and the rate the insurance company paid. I hope this helps.

[am_sa_lp]

This is a very bad situation. You may be lucky to get the insurance to pay for some of it, but it will require you work with the billing department of the Dr's and the insurance company to make sure that it is all paid.

I hope your knee is healing and it starts to feel better.

[Money Beagle]

I agree that you will have to most likely end up paying this out of your pocket but that you should look for some sort of break from the doctor. One thing I might start with is to talk to your insurance company and find out what the standard reimbursement would have been for an in-network provider. Say the billed cost for the procedure was $3,000 but the insurance company would normally pay $1,000 to an in-network provider. You might use this as a starting point in negotiating with the surgeon. They might come back and say 'no' because they specifically aren't a provider because of that low rate, but at least it gives you a starting point.

This is a bummer, but it teaches the lesson to always check. Whenever my wife or I is going to a doctor we haven't seen, the first thing I do is log onto our insurance website and find out if they are in network.

Good luck and hope things work out with both the insurance and the knee. Keep us posted.

[theCase]

I'm surprised that between the first doctor visit and the surgery that the insurance company didn't contact you as this is elective surgery and often Insurance companies require their permission (if you want THEM to pay!).

That being said, it truely is YOUR responisibilty for this. There's no way I would have gone in for any elective surgical procedure without talking to the insurance company.

Not specific to this post, but I am personally gettting sick of the "Wahhh, I'm a victim" mentallity being exhibited by this country. People need to be more self-reliant and be in charge of their lives. OK, I'll get off my soapbox now.

[Paul]

The advice from Kate above is good -- don't assume they've processed all of this correctly. Contracting with the insurace companies is usually done at the practice level, not the doctor level. If your doctor is in network, I'd be suprised if one of his partners from the same practice is not. Thoroughly make sure this was all processed correctly. You'll need to get your insurer on the phone for that.

If you are stuck with some or all of the bill, ask that your surgeon discount the bill to what your insurace would likely pay if in-network. It will probably be about 60% of charges. You'll at least get a decent discount, but only do that after thoroughly confirming that they are out-of-network.

The case of an anesthegiolost coming from out-of-network to give you your drugs is frustratingly common. Healthcare needs to make an exception for that. You even hear of cases where a woman in labor wants an epidural, and the guy who gives it is out-of-network. When you're in labor, are you really going to ask if he is contracted with your insurer? Give me a break.

[Jon]

My wife and I had good luck in the past with this sort of situation by filing an appeal letter with the insurance company. We'd gone to an in-network hospital which then referred us to a neurosurgeon who was out of network. As it turned out, there were no in-network neurosurgeons in the immediate geographical area, so that worked in our favor, as well.
We had to file an appeals letter, detailing all of the reasons we felt it should be covered, but ended up getting reimbursement at the in-network rates. Insurance companies aren't all evil, they'll generally work with you if you follow their appeals process.
The other thing that some have mentioned here, and I'd like to reiterate is that you CAN negotiate with the surgeon for a reduction in his fees, independent of whatever the insurance company decides. Often, providers will give you a significant discount for paying a large bill in full, rather than making payments over time. They don't want to mess around with billing over the long term, in many cases.
Good luck.

[Terri]

My business is medical billing, it amazes me how little the insured knows about what their insurance covers and what the requirements are to get their claim paid plus their deductibles and OOP expenses.
I know I have to deal with irate patients who don't want to pay their deductibles, copays etc and they can get very nasty and ugly.

I agree with Hickepedia, it's all that you can do, speak with the billing dept, insurance company and the providers offices and make payment arrangements.

Good luck!

[Cloe Sill]

Be patient but persistent, carefully document what anyone you talk to says, and continue to pursue it. There is always something that can be done.

[Jim]

Lot of good advice already so I'm mostly reiterating.

1) Double check everything and make sure you know the situation for sure. i.e. make sure what was/wasn't covered and whos responsibility it was to tell who.

2) Appeal the insurance and see if they'll cover it or make some adjustment.

3) If you have to pay out of pocket then talk to the doctor and see if they'll cut you a break on the cost.

You may be out of luck getting the insurance to pay since I do think its generally the patients responsibility to make sure that treatment is covered.

Here's a couple references:
http://www.bankrate.com/brm/news/insurance/20050726a1.asp
http://thyroid.about.com/cs/newsresearch/a/insurancepay.htm

[Barb]

A similar situation happened to me, keep pursuing, when I called the office billing clerk, she made a couple of phone calls and found out they were really in network... just keep bugging them until they get tired of hearing from you

[Lynn]

Be persistent in following up with this. I had a billing error which took me over a year to clear up. Finally, in the end I got to the right person at the right place and my $1600 balance became $0. I talked to people in the finance dept where I was seen, my insurance, the billing company (they handled the actual bill, not the hospital). There were times when I felt like they were giving me the run around and I felt like giving up.

1) Keep a log of your inquiries: time & date called, person you spoke with (where they work: insurance, billing, providers office *** try speaking to the person that does the billing in the office and not the receptionist), their direct extension.

2) Always, ask the person to make a note in your account, that way the next time you call it will be documented for whoever is helping you.

3)If you mail anything, make a copy to keep yourself and send it certified with return receipt.

Best of luck! Its absolutely maddening to me to deal with these things. I find its a little less stressful for me if I pick a day to schedule these types of calls. I'll save my EOBs & bills and make payments/follow up calls & inquiries every 2 weeks on Thursday.