"OUT OF NETWORK"

151949 · ‎03-09-2010

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.

151949 · ‎03-09-2010

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".

Lipstickdiva · ‎03-10-2010

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.

Lipstickdiva · ‎03-10-2010

@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.

DiAnne · ‎09-22-2010

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

151949 · ‎03-09-2010

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.

Lipstickdiva · ‎03-10-2010

@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.

151949 · ‎03-09-2010

@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.

Lipstickdiva · ‎03-10-2010

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.

hoosieroriginal · ‎03-04-2012

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!