In network/out of network consults

151949 · ‎03-09-2010

So many times here on this board we have discussed that when you are in an HMO/PPO type of insurance you can get skunked when you go to your in network hospital and they consult a specialist to see you and he turns out to NOT be in network. This especially happens often with anesthesia doctors and radiologists. The facility and your surgeon are in network but the doctor who gives the anesthesia or reads the x ray is not. It's not like you have any control over this. This happened to us when my DH had his stroke - there is only one neurologist on staff and she was not in network. Fortunately, our insurance paid it for us as an in network after we called and made a fuss. Anyway - it was on our morning news here that Florida has passed a law against this practice. If you have no control over who is consulted - say a radiologist - then the insurance must pay as an in network doctor, not the patient. They said this law only exists in 5 states. So GOOGLE it ladies and if this is not a law in your state - start writting your state legislators. This should be a federal law, but we should try to at least get it passed in the various states.

Tinkrbl44 · ‎08-23-2010

@151949

Excellent point ..... I learned long ago that doctors change where they are Providers at the drop of a hat. It can be such a real hassle, that's for sure!

PINKdogWOOD · ‎05-13-2010

This really is unfortunate but lucky for DH and me, our hospital is in network as are, don't think I'd be remiss to say, 995 of all Drs & specialists are also in network who are affiliated with our hospital.

We were led astray by our dentist when I retired and checked with our (then and still) our dentist as receptionist told us, sure we take your insurance. What she/they did not tell us what that they are out of network for our dental coverage. We get burned badly when we go to them. We LOVE our dentist and really don't want to change, to find one in network, but they do cost us a pretty penny if/when we need further work done ie cavities, crowns - crowns are crazy expensive too.

Our vision ins is pretty great though because we have many businesses we can go to that are in network, Lens Crafters has become our go-to choice and they constantly have great offers that we take advantage of in addition to our insurance. His glasses cost much more than mine because he works outside and needs more beneficial bells & whistles for protection so we don't complain about vision care.

Lucky for you in the sunshine state that your new law has passed WOW - in YOUR favor. Now there's a surprise to benefit the consumer.

2blonde · ‎03-10-2010

You re so right. The patient (often an older or incapable person) should not have to deal with this problem. As a patient, we have enough to deal with already!

Laura loves cats!

Melania · ‎06-12-2013

Well said OP! Thank you for pointing this out. I only wish other states would do the same!

It is not right that they do this and when one has an emergency there are no options. No one is even thinking about that when care is critical. Even when we have elective surgery it can be difficult.

lulu2 · ‎03-09-2010

@PINKdogWOOD wrote:

We were led astray by our dentist when I retired and checked with our (then and still) our dentist as receptionist told us, sure we take your insurance. What she/they did not tell us what that they are out of network for our dental coverage. We get burned badly when we go to them. We LOVE our dentist and really don't want to change, to find one in network, but they do cost us a pretty penny if/when we need further work done ie cavities, crowns - crowns are crazy expensive too.

Our dental insurance pays the same amount whether or not a dentist is in or not in network. The difference is whether they pay the dentist directly or reimburse us. Either way there is always a balance as our insurance pays only $1500. (which doesn't even cover 1 crown)

At least with medical insurance doctors or hospital in network settle for the amount the insurance offers them.

granddi · ‎03-16-2010

Here's a new one concerning "In or Out of Network".....A family member went for wellness check up and got the usual blood work.

She got a bill saying insurance did not pay for blood work.

Called insurance and was told the LAB was out of network. What!

I heard that SOME insurance clerks are bonused for denying claims. Something has got to change...............

151949 · ‎03-09-2010

@granddi This IS something she should have called ahead to confirm before she went to that particular lab.

aubnwa01 · ‎03-09-2010

I'm of an age where I now just get a pap every 3 years as part of the well woman stuff. I had one last year & 3 years prior. On the one 4 years ago, I got a bill from the lab that my dr.'s office had sent it to to process. It was only like $50 or so, but it should've been covered by my insurance. After checking with the lab & also the billing dept. of my dr.'s office, I found that someone somewhere had coded it as a cervical biopsy. Firstly, it was just a plain pap test, no biopsy & secondly, I had a hysterectomy in 1993 & don't even HAVE a cervix to be biopsied. My dr.'s office ate the charges, since it was a coding error on their part & I thought that was that. Last year, I had my every 3 year pap again & I even told the PA who did it to be careful of how it got coded, because of the mix up 3 years ago & wouldn't you know it, they did it again! My dr.'s billing office took care of it again & the gal said she made a note in my records, but we'll see! I'm now on Medicare with a supplemental Medigap policy, so it will be interesting in 2 more years, or I may have changed dr.s by then, which i've been thinking of doing.

Mary Bailey · ‎03-09-2010

@granddi I have worked for three insurance companies over 26 years as a claim processor/CSR. Never was there a bonus for denying claims.

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It is also my experience:

Out of network, they can bill whatever they want. Take your insurance, usually means they will take what the insurance pays and bill you the difference.

In network they have to write off whatever is over their allowable. They cannot balance bill.

Providers are may be contracted individually not as a group. Sometimes they are independent of the hospital or clinic. They can be in network at one address and out of network at another address.

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When DH had a stroke 12 years ago, BCBS paid everyone as in network. I did have to call them and tell them we had no choice in any of the providers.