topic Re: "OUT OF NETWORK" in Wellness

"OUT OF NETWORK"

151949 — Tue, 01 Mar 2016 19:10:27 GMT

I had a mammogram this morning - as if that isn't a bad enough way to start the day , as I was leaving the receptionist calls me over to say I should check with my insurance because they may no longer be "In network" with my insurance. My heart fell to my stomach! OMG - how much is this going to cost? I got home and called my ins co and they said the center was no longer in their network but that they had a legal responsibilioty to inform me of that before the test was done, not after. She said I will get a letter denying the coverage then I can call and my ins co will fight with the radiology center and make them do it free because they had a responsibility to notify me they were no longer in network. What a pain in the neck ! I feel certain that receptionist looked up my insurance and knew while I was sitting in the waiting room it would not be paid for. There was only me and a couple other people there , so they were not busy.

I'm mad at myself too for assuming that just because they have been in network for the past 5 years that they still are - I'm usually so careful about stuff like this.

Re: "OUT OF NETWORK"

151949 — Tue, 01 Mar 2016 19:18:13 GMT

Update - my BFF has the same insurance I do and I called her to tell her about my experience this morning and for her to check because I know she has some pre op testing scheduled there this month. She just called me back and they told her they are an in network provider with our insurance. HUH? But just to be safe she did call the insurance co and get it preapproved in case they aren't. Someone somewhere is lying. And I did look it up on the computer and it wasn't there - the representative at the ins co also did not find it listed on the computer. What the heck??? In the meantime DH called the radiology site to ask if they take our insurance and they said "sure".

Re: "OUT OF NETWORK"

Lipstickdiva — Tue, 01 Mar 2016 19:19:14 GMT

I wouldn't trust what your insurance company said about it being the center's responsibility to inform you before the test that they are out of network for you. I would think it's your responsibility to make sure where you are going is in-network.

I'm not sure how your insurance works but with my insurance, if I go to an out-of-network doctor or facility, my insurance pays 60% and I have to pay 40% of the bill.

I just ran into a problem where my insurance paid something as out-of-network and sent me an EOB saying they were paying 60% and I had to pay the rest. However, something was entered wrong in their system and the doctor was in fact in network. I appealed the claim and my insurance company paid the remaining amount of the bill.

Re: "OUT OF NETWORK"

Lipstickdiva — Tue, 01 Mar 2016 19:24:00 GMT

@151949 wrote:
Update - my BFF has the same insurance I do and I called her to tell her about my experience this morning and for her to check because I know she has some pre op testing scheduled there this month. She just called me back and they told her they are an in network provider with our insurance. HUH? But just to be safe she did call the insurance co and get it preapproved in case they aren't. Someone somewhere is lying. And I did look it up on the computer and it wasn't there - the representative at the ins co also did not find it listed on the computer. What the heck??? In the meantime DH called the radiology site to ask if they take our insurance and they said "sure".

I have little to no faith in CS at my insurance company. I had an issue last year with a cholestrol test that wasn't paid for. Everytime I called there, I got someone else who gave me a different answer.

Then when I got my first EOB about my out-of-network incident, I called because I knew the doctor was in network. He saw me at a hospital. I was told he was in network and so was the hospital but his visit in that hospital to see me wasn't in-network under my plan. That made no sense to me so I appealed and they paid the remaining $100.00.

Then I saw him at his office a month later and again, got an EOB saying he was out of network when my insurance's own website has him listed as a provider. Not to mention, when I called about this prior I was told he was in network.

I had to appeal that as well and once again, it was determined he was in network and they paid the rest of the bill.

Re: "OUT OF NETWORK"

DiAnne — Tue, 01 Mar 2016 19:25:15 GMT

It just sounds like the receptionist made an error. Reception is an entry level job.

Re: "OUT OF NETWORK"

151949 — Tue, 01 Mar 2016 19:26:18 GMT

if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

Re: "OUT OF NETWORK"

Lipstickdiva — Tue, 01 Mar 2016 19:27:01 GMT

@151949 wrote:
if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

Yeah I have a PPO. I didn't know that about an HMO. I've never had one.

Re: "OUT OF NETWORK"

151949 — Tue, 01 Mar 2016 19:32:25 GMT

@DiAnne wrote:
It just sounds like the receptionist made an error. Reception is an entry level job.

I don't think it was an error on the receptionist's part because I and the ins co rep both tried to find it on the computer and it is not there. So, for right now I totally do not know if I am covered for this or not. DH said if we get a letter we will deal with it, until then there is nothing we can do.

Re: "OUT OF NETWORK"

Lipstickdiva — Tue, 01 Mar 2016 19:33:51 GMT

If you were getting a screening mammogram, all things considered they really aren't that expensive, in case you do have to pay for it.

Re: "OUT OF NETWORK"

hoosieroriginal — Tue, 01 Mar 2016 19:36:18 GMT

I feel the mammographer should tell you if it is not covered by your insurance. I had a mammogram ordered by dr because I found a lump and because it was a "special" mammogram, my insurance did not cover it. I was absolutely furious and said they should have told me that before I had the mammogram. They are now getting $20/mo to pay it off - they can wait for their money!

Re: "OUT OF NETWORK"

SeaMaiden — Tue, 01 Mar 2016 19:38:30 GMT

Yes. It is important to be proactive and call and verify before surgery or checkups that everyone you are going to see are in network.

Re: "OUT OF NETWORK"

hopi — Tue, 01 Mar 2016 19:41:26 GMT

@151949 wrote:
I had a mammogram this morning - as if that isn't a bad enough way to start the day , as I was leaving the receptionist calls me over to say I should check with my insurance because they may no longer be "In network" with my insurance. My heart fell to my stomach! OMG - how much is this going to cost? I got home and called my ins co and they said the center was no longer in their network but that they had a legal responsibilioty to inform me of that before the test was done, not after. She said I will get a letter denying the coverage then I can call and my ins co will fight with the radiology center and make them do it free because they had a responsibility to notify me they were no longer in network. What a pain in the neck ! I feel certain that receptionist looked up my insurance and knew while I was sitting in the waiting room it would not be paid for. There was only me and a couple other people there , so they were not busy.
I'm mad at myself too for assuming that just because they have been in network for the past 5 years that they still are - I'm usually so careful about stuff like this.

So sorry this happened to you. Some people in health care are so horrible it's a disgrace. I know you came to vent your frustration but hopefully it will work out.

Re: "OUT OF NETWORK"

Lipstickdiva — Tue, 01 Mar 2016 19:47:10 GMT

@hoosieroriginal wrote:
I feel the mammographer should tell you if it is not covered by your insurance. I had a mammogram ordered by dr because I found a lump and because it was a "special" mammogram, my insurance did not cover it. I was absolutely furious and said they should have told me that before I had the mammogram. They are now getting $20/mo to pay it off - they can wait for their money!

A mammographer doesn't have anything to do with billing or insurance. They are the ones doing the scan/x-ray and that's it.

For very expensive tests like an MRI, sometimes my doctor will get pre-approval from my insurance company. But for routine things like mammograms, they do not. It's up to me to go to a facility that is in-network.

I'm not sure what kind of "special" mammogram you had to have done that wouldn't have been covered, especially since they found lump. Is it possible you had to pay because you hadn't met your deductible?

That is what happened with me last year. I had to have a diagnostic mammogram, which is more in depth so to speak, than a screening mammogram. I hadn't met my $1500.00 deductible yet with my insurance so I had to pay a huge chunk and my portion was nearly $600.00.

Re: "OUT OF NETWORK"

Moonchilde — Tue, 01 Mar 2016 19:48:18 GMT

@151949 wrote:
if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

And therein lies your problem. The office may be in network for PPO or individual policies but not for HMOs. So they could and would say that you were in network if you didn't remind them you were an HMO patient. And yes, unfortunately not every front office person has all the info and experience they should. I would in future ask to verify with/speak to the insurance person specifically in any future office. But even before that, I would ask at your HMO GP provider's office if they're sure that whatever office they're referring you to is in the HMO network. More leg to stand on, IMO.

Every office I have been in has a sign somewhere in the front (and often multiple signs to include the exam rooms) that it's the patient's responsibility to verify coverage and that the patient is responsible for any charges their insurance doesn't pay - but I understand your unhappy surprise, as it's not always easy to remember everything to do with insurance all the time.

Re: "OUT OF NETWORK"

ChynnaBlue — Tue, 01 Mar 2016 20:01:42 GMT

@151949 wrote:
if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

I always check with a doctor or lab before I make an appointment or while I'm calling to make an appointment if I cannot get the information online. I'm sorry you've had a very expensive lesson. Insurance companies are the worst.

Re: "OUT OF NETWORK"

151949 — Tue, 01 Mar 2016 20:09:08 GMT

@Moonchilde wrote:
@151949 wrote:
if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

And therein lies your problem. The office may be in network for PPO or individual policies but not for HMOs. So they could and would say that you were in network if you didn't remind them you were an HMO patient. And yes, unfortunately not every front office person has all the info and experience they should. I would in future ask to verify with/speak to the insurance person specifically in any future office. But even before that, I would ask at your HMO GP provider's office if they're sure that whatever office they're referring you to is in the HMO network. More leg to stand on, IMO.

Every office I have been in has a sign somewhere in the front (and often multiple signs to include the exam rooms) that it's the patient's responsibility to verify coverage and that the patient is responsible for any charges their insurance doesn't pay - but I understand your unhappy surprise, as it's not always easy to remember everything to do with insurance all the time.

So what - i specifically gave her my 2016 insurance card and it says right on it that it is an HMO. It actually says so in very large letters.

Re: "OUT OF NETWORK"

Tissyanne — Tue, 01 Mar 2016 20:25:50 GMT

It is the patient's responsibility to make sure they are in network. Just because a place "accepts your insurance" does not mean you are in network. Didn't your doctor refer you to a place and you refused so you could go to the one close enough to walk to?

Re: "OUT OF NETWORK"

Mj12 — Tue, 01 Mar 2016 20:33:54 GMT

@Tissyanne wrote:
It is the patient's responsibility to make sure they are in network. Just because a place "accepts your insurance" does not mean you are in network. Didn't your doctor refer you to a place and you refused so you could go to the one close enough to walk to?

True - many doctor's offices will "accept" anything. Doesn't mean at all that it is in network.

Re: "OUT OF NETWORK"

Melania — Tue, 01 Mar 2016 21:56:11 GMT

@151949 wrote:
@Moonchilde wrote:
@151949 wrote:
if you have a PPO you can go out of network and they pay it but I have an HMO and they do not pay anything for out of network.NOTHING.

And therein lies your problem. The office may be in network for PPO or individual policies but not for HMOs. So they could and would say that you were in network if you didn't remind them you were an HMO patient. And yes, unfortunately not every front office person has all the info and experience they should. I would in future ask to verify with/speak to the insurance person specifically in any future office. But even before that, I would ask at your HMO GP provider's office if they're sure that whatever office they're referring you to is in the HMO network. More leg to stand on, IMO.

Every office I have been in has a sign somewhere in the front (and often multiple signs to include the exam rooms) that it's the patient's responsibility to verify coverage and that the patient is responsible for any charges their insurance doesn't pay - but I understand your unhappy surprise, as it's not always easy to remember everything to do with insurance all the time.

So what - i specifically gave her my 2016 insurance card and it says right on it that it is an HMO. It actually says so in very large letters.

So what??

It's a big deal because YOU relied on the receptionist to handle it when they are already stressed to the max and not always trained to know all the different insurances and plans etc. Not only that many of them are just space fillers who have no real training.

Not many staff do...they have a special department for that. Oh and it doesn't matter that the office wasn't busy at all.

Aren't you on medicare? Maybe it would be more cost effective to get a better supplement as this seems to happen often.

Re: "OUT OF NETWORK"

Scooby Doo — Tue, 01 Mar 2016 21:59:46 GMT

Since I am covered by Medicare it doesn't matter where I go to get a mammogram. Medicare pays for it once a year, and my secondary insurance is not billed.