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Healthcare - out of network expenses

Healthcare - out of network expenses

Old Sep 20th 2019, 1:48 pm
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Default 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?
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Old Sep 20th 2019, 2:04 pm
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Default Re: Healthcare - out of network expenses

Just what you need at such a traumatic time eh?

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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Old Sep 20th 2019, 2:15 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 2:31 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 2:37 pm
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Default Re: Healthcare - out of network expenses

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.

Last edited by petitefrancaise; Sep 20th 2019 at 2:45 pm.
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Old Sep 20th 2019, 2:52 pm
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Default Re: Healthcare - out of network expenses

Very glad your wife is going to be ok. Give her a big hug from me.
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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Old Sep 20th 2019, 3:00 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 3:09 pm
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Default Re: Healthcare - out of network expenses

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.

Last edited by Jsmth321; Sep 20th 2019 at 3:13 pm.
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Old Sep 20th 2019, 3:22 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 3:41 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by newadventure View Post
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
The hospital we used was in network, but there was a sign saying not everyone working there was.
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Old Sep 20th 2019, 3:44 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 3:55 pm
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Default Re: Healthcare - out of network expenses

this looked like a good place to start arming yourself...
https://www.commonwealthfund.org/blo...tion-necessary
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Old Sep 20th 2019, 4:01 pm
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Default Re: Healthcare - out of network expenses

Sorry to hear about this, I hope your wife continues to do well.

I had this once where the facility, doctors etc were all in network but biopsies were sent to 2 different labs and one of them was not in network. $1,000 charge rejected by the insurance company and the written appeal was rejected. It took almost a year before finally the insurance company agreed to pay a portion and the lab dropped its charges dramatically. I ended up paying about $50 for my share of that lab test.

Good luck, stick with it.
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Old Sep 20th 2019, 4:23 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by newadventure View Post
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
I am really sorry you are being put through this, especially at such a traumatic time in your lives. The hospital should be ashamed.
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Old Sep 20th 2019, 8:22 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by newadventure View Post
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
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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