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Honored Contributor
Posts: 23,880
Registered: ‎05-10-2010

The insurer is correct, the radiology provider should have told you before the procedure that they were out of network and they should have told you what your out of pocket expenses would be.  I don't think the insurer will fight for you at all, I do this for a living and there is no reason or mechanism for the insurer to do that.  They didn't do anything wrong.   Now...you can and should do it.  You need to call the radiology provider and speak with the billing manager or the authorization manager and complain.  Tell them that you should NOT be responsible for their failure and insist that they write off the difference.  I work for a hospital and this type of situation is not rare but when we make a mistake. we own up to it and do what we can for the atient.

Honored Contributor
Posts: 18,504
Registered: ‎05-23-2010

@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.


 

To quote your very gracious response above - so what?

 

Seeing snark where it wasn't intended is a very bad habit. It stands out like a sore thumb. It's how posters get reputations. I'm okay with mine, BTW 😎

Life without Mexican food is no life at all
Honored Contributor
Posts: 18,504
Registered: ‎05-23-2010

@Melania wrote:

@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.

 

 


 

 

And I love how half a dozen people said exactly what I did and I said less judgmentally than some, but the only person the OP whizzed at was me. Busted. I could post "I love puppies" and she would do the same.  SMH.

Life without Mexican food is no life at all
Esteemed Contributor
Posts: 5,597
Registered: ‎11-15-2011

Re: "OUT OF NETWORK"

[ Edited ]

A business can take your Insurance  but not your particular plan. 

 

Respected Contributor
Posts: 2,905
Registered: ‎06-23-2014

@chrystaltree wrote:

The insurer is correct, the radiology provider should have told you before the procedure that they were out of network and they should have told you what your out of pocket expenses would be.  I don't think the insurer will fight for you at all, I do this for a living and there is no reason or mechanism for the insurer to do that.  They didn't do anything wrong.   Now...you can and should do it.  You need to call the radiology provider and speak with the billing manager or the authorization manager and complain.  Tell them that you should NOT be responsible for their failure and insist that they write off the difference.  I work for a hospital and this type of situation is not rare but when we make a mistake. we own up to it and do what we can for the atient.


You can fight it with the provider. I did once with a lab and they finally wrote it off. BUT it's not their responsibility to tell you. They should, and most do. It is ultimately your responsibility to check with your insurance carrier before anything. They do often change. I solved the problem after my encounter by asking the provider flat out before having anything done. Just get in the habit of always asking. It's a pain!  Good luck. 

Respected Contributor
Posts: 3,570
Registered: ‎09-13-2012

@151949 wrote:

@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.


If I were you, I'd deal with it now because by the time a bill comes time will have passed and you won't have a leg to stand on.  I'd call the practice back and ask to speak to the office manager or billing person and try to get an exact answer from them.  Then you can mention that the receptionist told you that after you had the test.  This will give you the best chance of coming to some kind of resolution that is fair to you.

 

I think the office staff are supposed to deal with insurance issues before a patient is seen.  You might be able to get the insurer to pay for it if they were in network until recently.  I'd try to get them to do that if I could, as they should be paid, though not necessarily 100% by you.

Respected Contributor
Posts: 2,905
Registered: ‎06-23-2014

Re: "OUT OF NETWORK"

[ Edited ]

@Ms X wrote:

@151949 wrote:

@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.


If I were you, I'd deal with it now because by the time a bill comes time will have passed and you won't have a leg to stand on.  I'd call the practice back and ask to speak to the office manager or billing person and try to get an exact answer from them.  Then you can mention that the receptionist told you that after you had the test.  This will give you the best chance of coming to some kind of resolution that is fair to you.

 

I think the office staff are supposed to deal with insurance issues before a patient is seen.  You might be able to get the insurer to pay for it if they were in network until recently.  I'd try to get them to do that if I could, as they should be paid, though not necessarily 100% by you.



@Ms X wrote:

@151949 wrote:

@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.


If I were you, I'd deal with it now because by the time a bill comes time will have passed and you won't have a leg to stand on.  I'd call the practice back and ask to speak to the office manager or billing person and try to get an exact answer from them.  Then you can mention that the receptionist told you that after you had the test.  This will give you the best chance of coming to some kind of resolution that is fair to you.

 

I think the office staff are supposed to deal with insurance issues before a patient is seen.  You might be able to get the insurer to pay for it if they were in network until recently.  I'd try to get them to do that if I could, as they should be paid, though not necessarily 100% by you.



@Ms X That's a good point. My insurance carrier was sympathetic to what happened. Although they didn't pay it, they did contact the provider to try to help, and the lab reduced the bill to the contracted rate. I still fought with them because I did some research and found many people in the same situation. I believed they were doing it on purpose (not telling) and told them my next letter would be to the state insurance commissioner and my representatives. 

Respected Contributor
Posts: 3,570
Registered: ‎09-13-2012

Re: "OUT OF NETWORK"

[ Edited ]

@Reba055 I found out my optometrist hadn't been paid because they didn't like the code she used for my annual eye exam (which is covered 100%) and she didn't appeal within the six-month time period.  I called up Blue Cross and told them I paid for the benefit and how can I get medical care when they won't pay for covered items?  They agreed to pay it, as they should have.

 

This is slightly different, but I think if OP had been going there for her mammograms the insurer might cover it during what is kinda sorta a transition period.  If a mammogram is covered, it would cost them no more money to pay that office the contracted rate.  That's what I'd be shooting for anyway.

 

Honored Contributor
Posts: 30,990
Registered: ‎08-23-2010

I learned a while back that doctors and other providers go in and out of network at the drop of a hat.     

 

I guess the best thing to do (if you are pressed for time) is to arrive at the appointment early and specifically confirm they are still a provider.    

 

Or you can check before you go.

Respected Contributor
Posts: 3,926
Registered: ‎12-02-2013

For BlueCross Medicare insurance in PA, I found out the hard way that they no longer cover that part of an annual eye exam that deals with eyeglass testing.  Had to pay additional for it.  Since I only use " readers " from over the counter, I won't be permitting that test to be done...needless!!!!

 

Come to think of it, there was no notice in the opthamologist 's office either.

We make a living by what we get. We make a life by what we give.
Sir Winston Churchill