Healthcare - out of network expenses
 

Brief summary - wife diagnosed with breast cancer in June (confirmed stage 1). Lumpectomy in July, now on chemo. Hit her out of pocket max (£7,000) pretty soon. Have just received a bill for £10K that the insurers will not cover as the service (in this case anaesthesiologist) was not in network. We had checked the surgeon, oncologist, plastic surgeon were all in network but missed this one. Has anyone ever fought a claim like this, or get any advice on how to do so? Or are we likely to have to stump up the cash?
Thanks

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Just what you need at such a traumatic time eh? :angry_smile:

We had two occasions but nothing on the scale of yours. First time...I took hubby to the ER during the night with chest pains. Everything went OK, before being discharged the doctor asked if his attending could meet my husband. He came, shook hand and said everything was ok, bye. We got a bill for several hundred dollars...the attending wasn’t in network. Can’t remember whether we paid it...sorry.

The second time, hubby went to the cardiac specialist for result of a test. He was told the doctor was called to an emergency, would it be OK to see his assistant? Turned out the assistant wasn’t in network. We argued that the appointment was with the in network doctor and not with his assistant. The bill was cancelled.

I hope your wife is doing well and makes a speedy recovery.

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I would strongly dispute it. Were you given any choice by the hospital about the aneasthetist? Did they just assign one to you? Hospital was in-network?

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Thanks both. Yes, wife doing well and prognosis is good - which is the important thing here.
petitefrancaise i couldn't get to the pre-op meeting where this was discussed but i don't believe a choice was given. Hospital is in-network

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I had an emergency admission to hospital last year, one of the drs was out of network but bill was paid since I had not been given any choice about it and in any case was in no condition to make an informed choice. I thought this kind of behaviour from insurance/drs/hospitals was being regulated? Maybe someone with more knowledge will come along soon.
Very glad your wife is going to be ok. Give her a big hug from me.

a quick google search tells me this is called "balance billing" - some states have protection from this but definitely dispute it or at least negotiate to get it reduced. Google it, there's loads of info out there.

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Thanks, will do!
RE: regulation - i believe this varies state to state. We are in SC which tends to err towards the less regulated end of the spectrum.
Can i ask if the hospital picked up the bill in your case, or the insurers? I don't know if i should be trying to show that the hospital should have been more pro-active or the insurers are being unreasonable

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actually I just had a quick look at the bills and it was the ambulance that was out of network. Hence no choice since it was 911 call. The insurers "had" to pay and the ambulance company told me exactly what to say to the insurers to ensure it got paid. The insurers sent me a check and then I paid their bill.
Call the doctor's office and see if they can assist you, if possible ask to speak to their billing department (probably outsourced) to ask how to go about getting the insurers to pay for this. Tell them you are disputing it and leave it at that.

Personally, I think the doctor's should be more pro-active in letting you know they are out of network - god knows we sign disclaimers for everything else, why not that? "I'M OUT OF NETWORK, YOU GOOD WITH THAT?" would prevent a lot of painful surprises....

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I had this issue once. With a specialist that was part of a team of doctors all but the one in network. In the end it was covered as I didn't get to choose the doctor putting me under and first I met him was in the OR minutes before I was put under.

Took about 8 months of arguing but in the end they paid the bill.

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My wife had a similar issue last year. Her main doctor was called to an emergency and asked if she wouldn't mind seeing her assistant. Assistant was out of-network. We got a bill for (if I remember correctly) about $800. We disputed it as similar to JerseyGirl her appointment was scheduled with an in-network practitioner.

After a couple of disgruntled back and forth phone calls, they cancelled the bill.

Sending best wishes for you and your wife!

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The hospital we used was in network, but there was a sign saying not everyone working there was.

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Thanks everyone, that is very helpful and gives some hope. We will dispute it and see what happens. At the moment feels like a hefty kick in the knackers

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this looked like a good place to start arming yourself...
https://www.commonwealthfund.org/blo...tion-necessary

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I am really sorry you are being put through this, especially at such a traumatic time in your lives. The hospital should be ashamed. :thumbdown:

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There was another thread earlier this year where I posted some info on balance billing after being charged $13k by SF General for my wife's four hour emergency room visit. They initially billed me for the rest but fortunately there was a huge issue in San Francisco about their billing practices and they dropped their claim for the $10k. Anyway, balance billing is definitely a state by state issue, as is out of network emergency care billing. Oh, and even though California is one of the states with most protections, ambulance companies can still balance bill for whatever they want. It's truly insane.

If I were in your shoes I'd investigate what state protections there are about billing for out of network providers being involved in a surgery. I wouldn't be too hopeful there are any though given that we are talking about North Carolina.

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To be fair - and not that I'm in any way defending this - is it really the hospital's fault?

I've always been under the impression that most medical professionals in the US are effectively independent contractors, and it's up to the individual providers - in this case the anesthesiologist - what insurance companies they will or won't accept.

I'd go as far as saying that certain providers KNOW that they are out of network if they practice at a certain hospital, and that's exactly why they practice there :(

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Thanks again. We are in SC - pretty sure there isn't any balance billing regulation here.

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none :-(
https://www.commonwealthfund.org/pub...ng-protections

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I'm so sorry your wife had to go through this with breast cancer. My daughter was diagnosed with stage 3 breast cancer last August 10th.

I thought the UK had national heathcare services and there were no charges to patients for doctors and/or treatments. Why do you have a deductible on your NHS and a network provision. Are you talking about a private healthcare policy that you have in the UK?

OOOPS! You used the pound sign but you are living in the US and should have been using the $ sign.

Happened to me once but insurance paid a small portion of the out of network bill and I negotiated the rest of the bill with the doctor's practice and the remainder of the bill was discounted by 60% and I paid that out of pocket.

Daughter with the cancer has no insurance. She negotiated the surgeon's bill, the hospital bill, and the anesthesiologist bill for cash payment and she paid that upfront. The hospital with surgery, OR, two nights stay, drugs, intravenous, etc. came to $19,000 and change. The surgeon charged her $3,500 and that included all followup visits.

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They are in SC Rete...not the UK. ;)

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I discovered that ... see my edited post.

He used the pound sign not the $ sign. :rofl:

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P.S. Remember that the medical expenses, if there is enough with expenses, OTC meds, deductibles, premium costs (anything not reimbursed with your healthcare savings account) is taxable deductible.

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Only the portion that exceeds 10% of adjusted gross income. Used to be 7.5% but Trump's tax changes altered that.

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Good point. If your out of pocket expenses are high, then you can itemise all your deductions and health care expense that exceed 7.5% of your income can be added to your itemised deductions. If your health insurance premiums are paid with after tax money then these can also be added to the health costs deductions. (If you pay insurance through an employer scheme then those premiums are before tax so can't be included).

https://www.thebalance.com/deducting...urance-3974024

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You're likely to have to pay it - the hospital will no doubt have some statement somewhere in something you signed that states that they may be in network but that all their MDs may not be. You might be able to kick up enough fuss with the insurance company that they agree, but I think it less likely.

The good news is that you can probably get at least 50% off that bill by negotiating.

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Most hospitals we have used here in Texas all use contracted groups for anesthesia and for the ER. You usually find out after the fact the first go round which is unfortunate. The problem is there is no choice as you have to use a hospital in network but still end up with ridiculous billing.

After M had carpal tunnel surgery a few years ago he was billed by 2 anaesethiologists for, and this was their words before he was taken back for surgery, " 5 to 7 minutes" of being anesthetized! Insurance covered a very small amount for one of them but as out of network it was minimal and totally declined the 2nd one as they deemed him unnecessary . We were stuck with two large bills that took almost 2 years of fighting to get them reduced. It is all so wrong.

OP, best wishes to you and your wife.

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Re the original poster.

i spent 20 plus years fighting such things, as a billing manager for Plastic surgery and for a medical billing service that included an anaesthesia group.

normal procedure is to write an appeal to your insurance company. If and when they deny appeal. Write a second appeal. (Do yourself a BIG favour and send them certified mail return receipt.
(Insurance companies seem to mislay a lot of letters and claims!!). Should that not work then you should contact your state insurance commisioner
(again certified mail)
It varies from state to state but if you can prove you took all reasonable steps to stay in network .....
Beat up on the hospital as well.. They have patient liason people that are supposed to help.
There are no certainties here but every patient i dealt with with this issue got some sort of positive result.

Good luck.
Wish you and your wife well.
Ps: keep every piece of paper!!!

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Thanks all, some very useful info here, we will appeal and see what happens. Thanks also for all the best wishes, it is not much fun but we are getting through it and ultimate prognosis is good

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OP: first, my best to you and your wife. Good luck in her recovery and remission.

I've personally never had a similar issue issue but I'm in a PPO. PPOs are generally much more liberal in their coverage of treatment from out-of-network providers. Also, I'm surprised with the errors people are talking about here. Any doctor / office /hospital I go to generally discusses insurance coverage and out of pocket expenses in great detail before they'll do anything, precisely to avoid these types of situations. The hospital the OP went to seems to be extremely unprofessional to have missed this. I would definitely dispute it.

OP: are you in an HMO? I deeply hate HMOs due to past experiences I've had. PPOs are, in general, much better to deal with. To others here: if you have the choice, I would definitely recommend paying the (potentially sizable) premium to go with a PPO.

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We had a PPO for 18 years. My husband nor myself cannot remember ever having any doctor/office/hospital ever mentioning or explaining insurance coverage or out of pocket expenses. Nor has the cost of a consultation/procedure/tests/surgery/follow up care etc ever been mentioned. Apart from whether they are in network or not, how do they know what your insurance company will cover, or what your costs will be?

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Absolutely. Same here, you can check if the hospital is in network but after that you have to wait for the billing especially if it is surgery. And we have now had 30 years experience of PPO's.

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Sorry but as a physician this is a ridiculous thing to say. Given there are thousands of plans etc how do you expect a clinician to know which one is or isnt in-network? Enough things for us to remember but not that thank you!

Preferably I would do away with insurance and go to a cash based model where patients pay directly an agreed price for the treatment or consultation. Lab work/imaging would again be charged at a fixed price.

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Are you a general practitioner? I ask because all the GP's I have worked for here in Texas always were aware which plans they were or were not in network with mostly because they had to have a contract with said insurance company.

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You have got to be JOKING!
Considering the amounts doctors are paid, surely it isn't too much to ask for one bloody phone call to the patient's insurers to check and that could probably be done by one of the many minions running around.
In the OP's case, this wasn't an emergency op, it was planned in advance so there would be time for a wee bit of admin. ESPECIALLY cosidering the ******* $10k it cost the patient
ETA
this kind of ****wittery aka balance billing is illegal in TX and other states. Funny how it can be done eh?

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I'm not saying you are overpaid. All I'm saying is if you write orders for Lab work do you ask your patient, for example: Is Quest Lab in network for you or is the hospital lab a better option ? If you do that it helps a lot of unnecessary billing problems. Sometimes sick patients appreciate a doctor more if they just take a little time to help with what may just seem small details.

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US doctors ARE paid more than other countries though.....
https://naibuzz.com/10-countries-hig...alaries-world/

and the bill for the hospital drs comes from their offices, not from the hospital, so I'm not sure that offloading the responsibility is relevant. Like I said, quite a few states have legal protection for patients against balance billing so it is possible to figure it out.

If you didn't want to bother your pretty little head over billing issues, then perhaps you might have stayed in the NHS?
Or you could go to France and earn about 1/3 of your current salary?

Re: Healthcare - out of network expenses
 

expatdoc Last Activity: Sep 9th 2019 10:19 am (banned)
ceat Joined: Sep 18th 2019

Just sayin'