Out of Network Provider

[Sharon Berger]

What is the name of your state?Florida

My husband was in the hospital for a test and it was determined by his doctor that a procedure was required. The doctor call me at home to describe the procedure and get my approval to proceed, which I gave verbally.

Two months later we received a bill from a doctor for an outstanding balance not covered by our insurance. That is when we found out my husband's doctor had called in another doctor to actually perform the procedure and that 2nd doctor was not part of our network. I have contacted several state agencies and they all consider this a billing dispute. I feel it is more, as this doctor knowinly accepted a case for a patient in whose insurance plan he did not participate. Our health insurance company says it is the patient's responsibility to verify all providers are part of the network. That is fine, except we did not know this other doctor was even involved. My husband's doctor's office says it is not their responsibility to verify that the doctor they call in for consult is part of our plan. Both the original doctor and the hospital had all my husband's insurance information and as is the care just about everywhere, you cannot get in to see a doctor or be admitted to a hospital without proof of insurance so do they not have some responsiblity here as well?

We have contacted the providing doctor to ask him to accept what the insurance has paid and he has refused. We contacted him again asking him to take a smaller amount before we would be force to go to small claims court with this dispute but they hung up on us. This has already been turned over to a collection agency.

Are we responsible for this outstanding balance? Do I have any options?

[cbg]

The doctor had no way of knowing whether the consulting doctor was or was not participating in your network. Even within the same carrier, several networks can and do exist. Just because he had your husband's insurance information doesn't mean that he automatically knows each and every doctor that is and is not participating; nor is it his responsibility to find out unless your insurance policy SPECIFICALLY says so.

Yes, you owe the bill. You received the services and the doctor deserves to be paid. You can TRY to get him to accept a lower amount but he has no legal obligation to do so.