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Healthcare - out of network expenses

Healthcare - out of network expenses

Old Sep 29th 2019, 1:19 am
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Default Re: Healthcare - out of network expenses

Originally Posted by spouse of scouse View Post
in fact I don't think he/she is a medical practitioner at all. Unless working in the hospital laundry counts.

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Old Sep 29th 2019, 7:48 am
  #47  
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Default Re: Healthcare - out of network expenses

Originally Posted by Jerseygirl View Post
There are ways get around IPs I have my eye on another poster too I call them our NHS troll No matter how they try to hide it we have our ways and means to sniff them out Sometimes trolls make a useful play thing

Sorry about no full stops my phone seems to have stopped typing them
Thanks for the intervention. I’m a Moderator on another forum so I know how tricksy trolls can be in disguising their online identity.

You all do a good job in keeping this site free of them.
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Old Sep 29th 2019, 8:00 am
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Default Re: Healthcare - out of network expenses

Originally Posted by Sugarmooma View Post
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.
I know the troll has left the room but you make a good point.

I remember being referred to a specialist once and at the appointment he said “I’m going to order a blood test now. Quest have an office in the building so if they are in network you can have it done before you leave today. Ask at the desk on your way out and they will check your plan and organize it”. It was hardly a difficult thing for the doctor to do, he simply needed to be aware of the cost to the patient. As it happened Quest was in my plan so it saved me some trouble.
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Old Sep 29th 2019, 5:43 pm
  #49  
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Default Re: Healthcare - out of network expenses

Most of the time I was in the US and was insured I had Kaiser and they provided pretty much everything in their facilities so I never encountered in or out of network with them, kind of makes me glad I never had to deal with all this in network, out of network stuff, seems like a royal pain to try and keep track of.
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Old Sep 29th 2019, 6:32 pm
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Default Re: Healthcare - out of network expenses

Originally Posted by Jsmth321 View Post
Most of the time I was in the US and was insured I had Kaiser and they provided pretty much everything in their facilities so I never encountered in or out of network with them, kind of makes me glad I never had to deal with all this in network, out of network stuff, seems like a royal pain to try and keep track of.
When we retired in 2010 I was able to keep my ex-employer group insurance but had to pay full whack, and with after tax dollars, but they still offered PPO plans which was essential as we immediately moved to Texas from Louisiana and the company HMO plans did not operate out of State. We also traveled extensively once retired so I became very adept at researching the in-network facilities in the places we stayed for weeks at a time including overseas locations. The only place I took out health insurance for was Vanuatu.
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Old Sep 29th 2019, 6:51 pm
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Default Re: Healthcare - out of network expenses

My dad retired a few years ago, he is currently on his employers group retirement plan, but its only valid within So. California, its not valid in Northern California or out of state, but he has no plans to move, his wife isn't able to retire yet so I think he fine with the limited options at the moment, I think he still too young for medicare and social security or is waiting until he is 65 in a few years.

Retirement healthcare when travelling seems to be a little tricky at times, even for Canada, there are time limits a retired person can spend outside their resident province and still maintain coverage, for BC if only travelling on vacation one cannot stay outside of BC over 7 consecutive months, otherwise have to spend a minimum of 6 months each calendar year in the province otherwise risk losing healthcare coverage.

Originally Posted by durham_lad View Post

When we retired in 2010 I was able to keep my ex-employer group insurance but had to pay full whack, and with after tax dollars, but they still offered PPO plans which was essential as we immediately moved to Texas from Louisiana and the company HMO plans did not operate out of State. We also traveled extensively once retired so I became very adept at researching the in-network facilities in the places we stayed for weeks at a time including overseas locations. The only place I took out health insurance for was Vanuatu.

Last edited by Jsmth321; Sep 29th 2019 at 6:54 pm.
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Old Oct 1st 2019, 2:02 am
  #52  
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Default Re: Healthcare - out of network expenses

Newadventure - firstly I hope your wife is doing OK. I'm a US certified medical coder 20 years - one of which I worked at United Healthcare. Questions I'd be asking - is the anesthesiologist currently being credentialed with this insurance company if so what is the date of the contract? Credentialing can take some time and until everything is in the system the claims will process out of network. Was the correct provider ID and/or tax ID submitted with the correct place of service? The anesthesiologist's claim is known as a RAPL (pronounced rapple) meaning, radiologist, anesthesiologist, pathologist, lab - these are all service the patient has no control over as they are assigned to the patient. When I worked at UHC as a provider rep - I'd send the claim number for the in network facility together with the in network authorization number and the RAPL claim back to claims and have them reprocess as in network. If there is no joy from the insurance company and the insurance is through your employer get some help from your benefits rep. Typically a patient doesn't meet the anesthesiologist until been wheeled back for the surgery. It's unreasonable for the payer to expect the patient at that point to call a time out to call the insurance company to see if the anesthesiologist is in network. Good luck and best wishes to your wife. Teawit86
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Old Oct 1st 2019, 8:27 pm
  #53  
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Default Re: Healthcare - out of network expenses

Hello again, sorry for silence - i was back in UK with work last week. Thanks for all good wishes and helpful advice (Teawit86 and others). Last chemo session tomorrow which is good. The plan we are on is a PPO provided by employer, but we are small (5 people in US). We have been speaking to the health insurance broker who has been very helpful and is in turn talking to the hospital to try and get the cost reduced to in network rates (to be clear, this would not be an in network charge, which would be covered, but to reduce the charge to the same as the in network rate). We have also contacted the Patient Advocate Foundation (anyone heard of them?) who are going to take the case up with the health insurance company. So far we have not been sent a bill directly, only notification that the insurance company is not paying the charge due to the provider being out of network. I guess when we receive the bill, we will then argue with the anesthesiologist
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Old Oct 26th 2019, 1:05 am
  #54  
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Default Re: Healthcare - out of network expenses

Originally Posted by petitefrancaise View Post
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....
who is your medical insurance company and who was the ambulance company?
i am in a similar situation.
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Old Oct 26th 2019, 1:48 am
  #55  
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Default Re: Healthcare - out of network expenses

Hi, I'm just down the road from you!
The ambulance was Austin-Travis County EMS. No choice in this one at all, you call 911 in my area and that is who you get. They told me they aren't in network for anyone.
Insurance Co is Aetna - plan is for "in-network" only.

I called the ambulance billing office first - they said that I should call Aetna, tell them this is balance billing and that they will not be writing it off and they should re-process the account using in-network benefits. This last part is word-for-word what they told me to say. They said they would give me another 30 days to pay and to call if there were any issues.

I did the above and Aetna told me to pay the ambulance directly and they would send me a check to cover it. I waited until I got the check (duh!) which was sent within a few days and paid up.
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Old Oct 26th 2019, 4:13 am
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Default Re: Healthcare - out of network expenses

My bill was from Georgetown Fire Dept EMS. They billed $1100. My insurance paid $450 and I got balance billed for the rest.
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Old Oct 26th 2019, 4:22 am
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Default Re: Healthcare - out of network expenses

Originally Posted by g1ant View Post
My bill was from Georgetown Fire Dept EMS. They billed $1100. My insurance paid $450 and I got balance billed for the rest.
yes. that was what happened to me - original bill was for ~$900. Insurance paid 50%. Then I got the bill for the remainder fromAustin EMS and this is when I called them. If it was a 911 call you don't get any choice over which EMS you get so the insurance has to pay as if it were in-network. Sounds like you should call Georgetown EMS and see what they say.
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Old Oct 26th 2019, 4:43 am
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Default Re: Healthcare - out of network expenses

Originally Posted by petitefrancaise View Post
yes. that was what happened to me - original bill was for ~$900. Insurance paid 50%. Then I got the bill for the remainder fromAustin EMS and this is when I called them. If it was a 911 call you don't get any choice over which EMS you get so the insurance has to pay as if it were in-network. Sounds like you should call Georgetown EMS and see what they say.
What great advice PF, I love it when BE works like this, connecting locals. You're a good egg!
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Old Oct 28th 2019, 6:15 pm
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Default Re: Healthcare - out of network expenses

I don't know what the law is in Texas, but in California - a state that has more balance billing protections than most - ambulance companies got themselves excluded from these protections. When I was on the team at my employer to deal with office emergencies, we were specifically told that we could only call an ambulance if an individual specifically requested one, unless they were completely unable to communicate. Crazy stuff.
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Old Oct 28th 2019, 6:32 pm
  #60  
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Default Re: Healthcare - out of network expenses

I've already posted this in another thread
https://www.commonwealthfund.org/blo...alance-billing

scroll down for a map of the states, click on the states to find out current law.

" In Texas, HMO and EPO members must be held harmless, but those in PPOs may be balance-billed. State law requires PPOs to disclose the possibility of balance billing to consumers and allows consumers to pursue dispute resolution for amounts of $500 or greater. Also, PPOs must base payments on usual and customary billed charges in emergency settings or those where no in-network provider is reasonably available. This minimum payment amount is designed to minimize the use of balance billing."
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