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Healthcare - out of network expenses

Healthcare - out of network expenses

Old Sep 20th 2019, 8:35 pm
  #16  
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Default Re: Healthcare - out of network expenses

Originally Posted by Jerseygirl
I am really sorry you are being put through this, especially at such a traumatic time in your lives. The hospital should be ashamed.
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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Old Sep 20th 2019, 9:07 pm
  #17  
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Default Re: Healthcare - out of network expenses

Thanks again. We are in SC - pretty sure there isn't any balance billing regulation here.
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Old Sep 20th 2019, 9:10 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by newadventure
Thanks again. We are in SC - pretty sure there isn't any balance billing regulation here.
none :-(
https://www.commonwealthfund.org/pub...ng-protections
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Old Sep 20th 2019, 10:14 pm
  #19  
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Default Re: Healthcare - out of network expenses

Originally Posted by newadventure
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
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.

Last edited by Rete; Sep 20th 2019 at 10:24 pm.
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Old Sep 20th 2019, 10:20 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by Rete
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?
They are in SC Rete...not the UK.
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Old Sep 20th 2019, 10:26 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by Jerseygirl
They are in SC Rete...not the UK.
I discovered that ... see my edited post.

He used the pound sign not the $ sign.
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Old Sep 20th 2019, 10:28 pm
  #22  
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Default Re: Healthcare - out of network expenses

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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Old Sep 20th 2019, 10:35 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by Rete
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.
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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Old Sep 21st 2019, 10:44 am
  #24  
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Default Re: Healthcare - out of network expenses

Originally Posted by Rete
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.
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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Old Sep 21st 2019, 11:28 am
  #25  
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Default Re: Healthcare - out of network expenses

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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Old Sep 21st 2019, 11:58 am
  #26  
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Default Re: Healthcare - out of network expenses

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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Old Sep 21st 2019, 9:00 pm
  #27  
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Default Re: Healthcare - out of network expenses

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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Old Sep 24th 2019, 9:57 am
  #28  
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Default Re: Healthcare - out of network expenses

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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Old Sep 25th 2019, 2:52 pm
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Default Re: Healthcare - out of network expenses

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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Old Sep 25th 2019, 3:08 pm
  #30  
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Default Re: Healthcare - out of network expenses

Originally Posted by Hiro11
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.
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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