Doctor sent me to a non-participating surgery center

[Jonathan1971]

What is the name of your state (only U.S. law)? California

I located a podiatrist on my participating provider directory and made an appointment. He recommended foot surgery and I agreed to it. He told me that he performed his surgeries at two different outpatient surgery centers, and that he preferred one over the other. He said he would check to see which one my insurance covered. His office called a few days later and notified me that surgery was scheduled at the center he had selected. I reported to surgery and everything went as expected. Now, four weeks later, I have received my Explanation of Benefits form from my insurance stating I owe the surgical center $26,000.00 because the surgery center was a non-participating provider. I am beyond shocked since I had given my insurance information to the doctor and he had informed me that he would verify I would be covered, but my insurance has now told me that, no, I am not covered. Do I have any recourse?

[ecmst12]

It is YOUR job to verify which facilities participate with your insurance, not your doctor's. You should have double checked with them before consenting to the procedure. Now you owe the money.

[FlyingRon]

Agreed. Is that the full amount. Doesn't your plan pay a lesser share for non-participating providers? You can the companies appeal procedure to see if you can get some funds.

[ecmst12]

There are lots of plans that pay nothing for non-participating providers. And if OP had one of those, then he should have been even MORE careful about making sure the surgery center was in network before he had the procedure.

[Jonathan1971]

Originally Posted by FlyingRon

Agreed. Is that the full amount. Doesn't your plan pay a lesser share for non-participating providers? You can the companies appeal procedure to see if you can get some funds.

My plan pays 50% of the negotiated rate of what they pay participating providers. They've paid $600. So a participating provider would have been paid $1200. How can the difference be so extreme. Seriously, $26,600 for a one-hour outpatient procedure? I checked in at 8:00am and my wife took me home at 10:00am.

[justalayman]

Originally Posted by Jonathan1971

My plan pays 50% of the negotiated rate of what they pay participating providers. They've paid $600. So a participating provider would have been paid $1200. How can the difference be so extreme. Seriously, $26,600 for a one-hour outpatient procedure? I checked in at 8:00am and my wife took me home at 10:00am.

the disparity between those two figures is so extreme, I would investigate them further. The $1200 does seem to be extremely low for any surgical suite for a few hours but the $26.6k seems to be an extreme as well. So extreme I would question the billing itself more than I would the doctors actions.

[Jonathan1971]

As it turns out, the doctor was fully aware that the surgical center was a non-participating provider but selected it anyway. The reason being he is part-owner of the center. He knew my insurance would only pay a fraction but he said they would rather have my business than not. The remaining $26,000 after $650 was paid by my insurance will now be written off. He represented that it is a non-issue for me and the figures are just that, figures. He stated the issue is between himself, the surgical center and the insurance company. Quite a scare for me all the same. I was not expecting such a bill.

[lkc15507]

Originally Posted by Jonathan1971

As it turns out, the doctor was fully aware that the surgical center was a non-participating provider but selected it anyway. The reason being he is part-owner of the center. He knew my insurance would only pay a fraction but he said they would rather have my business than not. The remaining $26,000 after $650 was paid by my insurance will now be written off. He represented that it is a non-issue for me and the figures are just that, figures. He stated the issue is between himself, the surgical center and the insurance company. Quite a scare for me all the same. I was not expecting such a bill.

You are extremely lucky. I'm fighting the "soap box" stance, but this is all too common. Physicians nearly never refer to a facility or another specialist based upon the best outcome for the patient. They refer based upon their own special interests, be it pocketbook or prestige. THEY VIRTUALLY NEVER CONSIDER NETWORK OR INSURANCE. That 26K was hugely disproportionate. Keep on your toes, don't let them do that to you. Ya know, most large networks, even small ones will provide access to excellent tertiary care. An individual physician doesn't ever consider the patient's pocketbook. He refers to his former professor, a friend in the speciality etc etc etc.

Folks, your Doc's word is not always law. lkc15507

[lealea1005]

Originally Posted by lkc15507

An individual physician doesn't ever consider the patient's pocketbook. He refers to his former professor, a friend in the speciality etc etc etc.
Folks, your Doc's word is not always law. lkc15507

Physicians nearly never refer to a facility or another specialist based upon the best outcome for the patient.

Those are very jaded, unfair statements.

Your referring Physician is responsible for your medical care. Mostly, referrals to sub-specialists are made because the referring Physician has a working relationship with them and is comfortable with the specialist's experience and expertise. Yes, they could be colleagues or former attending Physicians they knew from residency. They have a vested interest the outcome of your procedure/surgery/diagnosis. They should not have to worry about risking the quality of their patient's medical care because they are required to be swayed by a sub-specialist's network affiliation, or the patient's "pocketbook".

If you, the patient/consumer wishes to stay within your insurance network affliation, that is your right. You can, and should, call the insurance company to get the names of Physicians within that specialty that are contracted.