medical (legal?) advice
A doctor and a lawyer and an indian chief…
PHEW. Alright, where do I begin. Through some sort of devious paperwork pratfall I have suddenly been faced with a rather large increase in my estimated medical bills. I’ll lay out the details and let me know if you have any specific advice on how to proceed, given the idea that I have somehow been wronged. All the parties involved have been helpful in explaining the situation but I’m sure none of them care to deal with it or offer ways to mitigate my resulting financial burden. Really, everyone is sorry and knows that something is amiss but redress is out of their reach.
BRIEF:
The new surgery center my doctor utilized was not yet added to the in-network contract its parent company/hospital has with my insurance company. Neither the doctor’s office nor the surgery center notified me that the procedure was out-of-network. My insurance provider listed it as out-of-network and subtracted from my yearly deductible $600 of the $2,412.50 I am currently paying the surgery center rather than the entire amount. This amount represents the in-network amount the surgery center assessed at billing time (billing the insurance company for the full amount of $3,447.84). Minus prior deductible expenditures, this occurence represents an additional $1,582.49 in medical expenses that comes out of my pocket, which could have been avoided if my surgery could have been performed at an in-network surgery center. But the details below make the situation even more “unique.”
LONG:
My doctor’s office scheduled the surgery with a brand new outpatient surgery center located on the grounds of the hospital the doctor works through. This center is named associatively to the hospital and is owned and operated jointly by the hospital entity and individual physicians. The trainee that scheduled my surgery failed to specifically check that the new center was currently considered in-network regarding my insurance provider but did verify whether my deductible had been met.
According to my doctor’s office the new outpatient surgery center was, at the time of the surgery, operating under the assumption that they were currently under contract with my insurance provider. The surgery center stated that my insurance provider has paid other claims to this new center though it has not paid mine. However, the surgery center is not currently (or officially) under contract with my insurance provider. The process will be completed in the future as the surgery center must still be added to the existing hospital entity’s current contract with my insurance provider. The surgery center is currenly under contract with other insurance providers, which may add to the confusion with claims processing and verification.
I was never informed by either my doctor’s office or from the surgery center that my insurance would bill the surgery as service from an out-of-network provider. My doctor’s office indicates that the surgery center typically notifies them if a patient is out-of-network, while the surgery center indicates that the doctor’s office never explicitly asked if they were in-network. The doctor’s office normally checks if a surgery site is in-network given the patient’s insurance. In my case, a deductible check was done and nothing else.
The surgery center issued the original bill prior to my surgery and was able to determine an in-network price for which they issued and had me sign a 3-payment promissory note. They then billed the insurance company for the full out-of-network amount. Because of unfinished and on-going contract negotiations for the new surgery center, my insurance company does not accept this bill as an in-network provider and has allowed only $600 to be applied to my deductible ($2,500). Again, the surgery center has indicated that my insurance company has paid other claims to them but will not pay mine, which confuses me a great deal.
In summary, an initial omission by my doctor’s office in scheduling my procedure combined with the in-network contract limbo of a new surgery center has resulted in my insurance company witholding payment of approximately $1,582.49 in medical payments. I need advice regarding how to avoid paying this amount, or a large portion thereof, in a polite and legal manner.
ARGH!
I’ve asked lots of questions and it usually comes down to the parties indicating that things are somehow not quite right on their end but that someone else is responsible for handling the problem – or that there is no problem. Everyone is happy to help and sorry that they can’t do more. There must be some recourse.
My initial thought is that the doctor’s office is responsible because they schedule the procedure and verify coverage. The doctor should optionally be able to perform surgery at the hospital which is an in-network provider. The surgery center can’t help its contractual situation, however they seem to be giving the doctor’s office the impression that they have existing coverage when they don’t while also receiving payments from my insurance company. If my insurance company is paying claims to the surgery center, it would be very interesting to find out if they are in-network claims. Unless my doctor’s office wants to admit a mistake and help me out with some bill payments I’ll have to do some investigative work about those claims being paid to the surgery center. Perhaps the doctor’s office has some pull and could get something to happen with my insurance company? I doubt it.
The big fear for me and the worrisome loophole is the fact that I do not have some paper that says I asked specifically if this surgery site was in-network. I have also discovered that an associated anesthesiologist group involved in the procedure is not covered by my insurance and I have to swallow that bill because I was not given a list of costs and entities involved to verify. I’m told out-of-network anesthesiologists groups are typical. The surgery site and bulk of the cost should be fricking verified by the scheduling party. I deserve some sort of notice if the hospital is covered and the surgery center is not.
When I was presented with the promissory note the day of the surgery, I asked if this was being submitted to my insurance and if I was covered. They told me the deductible hadn’t been met yet and the charge was being submitted. I second guess everything, yet I wasn’t told anything that indicated the surgery center was not in-network or that I was not covered. After resubmitting the first round of rejected claims, the surgery center indicated that they spoke with my insurance provider and they would be sending a check because of the special situation. This changed with subsequent calls. The only upside is that from the outset they have charged me the in-network rate regardless of my status, though I’m not certain why. It does save me $1035.34 over the out-of-network cost, but I should only be having surgery at in-network locations especially when they are less than a block away.
Chako wants me to be agressive and be intimidating or upset, but I want to confront people in an appropriate manner. It’s hard to fight a three headed beast. I still have radiation therapy ahead of me so I don’t want my insurance company to get annoyed.
9 November 2004, 17:32 ::
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