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PPO In Network Hospital but Out of Network Provider

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mtcutler

Junior Member
Texas. Blue Cross Blue Shield (BCBS) PPO plan. Two week ICU stay at an 'In Network' hospital. We received numerous bills from different providers, some in network some out of network.

For out of network bills I contacted BCBS because the hospital is in network. BCBS agreed to re-classify the out of network statements to their in network terms since we had no choice of providers at the in network hospital.

I then contacted each of the providers. All but one agreed to the BCBS covered amounts and rebilled us as if they were in network. So far so good.

One hold out provider claims we have to pay their full prices, so the difference between the BCBS covered amount and their full price is in dispute. They tell me they canceled their contract with BCBS 12 days before services were provided.

What are my options? This appears to be a regular occurrence with PPO plans: the hospital is 'in network', yet many (most, it appears based on my bills) of the service providers at the hospital are 'out of network'.

1) Can BCBS claim the hospital is 'in network' when the majority of services provided there are 'out of network', and the patient has no choice once in the hospital who provides the services? This seems like false advertising and misleading information to me. BCBS appears to agree with this - they approved ALL services under their in network terms after I called them. I have documentation to show this.

2) Can I go back to BCBS and get them to pay the above provider's outstanding bills, with the argument that BCBS approved it as 'in network' and therefore they must take care of this provider's disputed amount as well? They've already told me the difference is my responsibility, which I have not responded to yet.

3) Can I claim that the provider falls under the hospital's status with BCBS as 'in network' since the service provider has a contract with the hospital, and the hospital has a contract with BCBS? Are there any other options for me with the provider?

4) This seems to be a widespread issue with PPO plans and 'in network' hospitals. Any links, references, etc., that explore this issue with the insurance industry?
 
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seniorjudge

Senior Member
mtcutler said:
I am a customer of a large Health Insurance provider in Texas, of which we are part of a PPO plan. My wife gave birth to our 4th son recently, and he spent two weeks in the ICU at an In Network hospital (PPO). We checked out the hospital ahead of time on our health insurance provider's website and called to make sure it was in network.

To summarize: One of the service providers at the hospital who we received a bill from is 'out of network' even though the hospital is 'in network'. They are charging us full 'out of network' fees and our insurance won't make up the difference from 'in network' fees. What are my options?

All the gory details and what I've done so far are below:

Since our son was released we have received numerous hospital and medical service provider bills and explanations of benefits from our insurance company (well over a dozen separate statements for the numerous services rendered from many different service providers at the hospital). Many of them show In Network, with the appropriate charges, payments, discounts, copays, deductibles, etc. But many of them show 'Out of Network' for a medical service provider who works at the hospital or provides services to the hospital. For these 'Out of Network' providers our bills show much higher fees based on the out of network terms of the PPO plan and higher non-negotiated, non-insurance-discounted rates. In each of these instances our insurance statement states that we 'chose' out of network and therefore did not receive in network benefits.

In each of these so called 'out of network' instances I have contacted the service provider and our insurance company to let them know the services were provided at an in network hospital and therefore fall under our in network terms. In ALL of these instances, our insurance provider has agreed to give us 'in network' PPO terms, because they agree that we did not have a choice who provided the services at their 'in network' hospital. This 'in network' status provides us with a higher level of coverage for the charges (percentage-wise), with a lower deductible and lower and separate out of pocket maximum (we easily reached the in network out of pocket maximum for the 2 week ICU stay). I have updated statements from the insurance company showing this.

MOST of the medical service providers have also agreed to the 'in network' terms with my insurance. This results in the provider agreeing to my insurance provider's discounted 'covered' amounts, and not charging me the 'uncovered' amounts. The covered amounts appear to be the discounted rates my insurance provider has with it's PPO's, and they are significantly less than the total billed amount, often more than 50% less than the total amount. In these instances I feel we have been treated fairly per the terms of our plan and our having done our part to stay in network. But this has not been an easy ordeal. It has taken a long time, a lot of effort and a lot of rummaging through complex insurance jargon, claims, forms, contracts, phone calls, etc., to get to this point. I imagine many customers don't take this time or cannot figure it out and just pay the difference. In this case the difference amounts to several thousand dollars. Note that this is not the first time this has happened to us. Similar has happened at least 4 times since we got on our PPO plan 2 years ago.

Now here's the outstanding problem. ONE of the medical service providers at the 'in network' hospital has not agreed to the lower covered amounts from my insurance provider. They are charging me the difference in uncovered amounts from covered amounts (the amount my insurance paid them). They tell me they canceled their contract with my insurance company 12 days before services were provided, and that I must pay the difference since they have no contracted rates with my insurance or with me. The difference is now in dispute.

What are my options? This appears to be a highly regular occurrence with PPO plans: the hospital is 'in network', yet many (most, it appears based on my bills) of the service providers at the hospital are 'out of network'.

1) Can my insurance company really claim the hospital is 'in network' when the majority of services provided there are 'out of network'? This seems like false advertising and misleading information to me. There is no way for me to check what is 'in network' vs. 'out of network' at the 'in network' hospital until after services are rendered, and I have no choice who provides services once I am at the 'in network' hospital for an emergency like this. My insurance company appears to agree with this - they approved ALL services under their in network terms, but only after I contacted them to dispute the matter. I have documentation to show this. If I had not disputed each claim I would have been charged out of network. I imagine many customers end up paying out of network.

2) Can I go back to my insurance provider and get them to pay the above medical service provider's outstanding bill, with the argument that they approved it as 'in network' and therefore they must take care of this provider's disputed amount as well? My insurance provider classified it 'in network' (I have the statement showing the adjustment to 'in network' terms for this service provider). Can I argue that they should therefore back that up fully, by giving me 'in network' terms, AND ensuring that I am not charged the 'uncovered' amounts by the now 'in network' provider? I haven't tried it yet, but I imagine they will state that this was a courtesy classification for their in network terms only, not for them to deal with a provider that they have no contract with, and that the difference in uncovered amounts is my responsibility. They've already told me the difference is my responsibility.

3) What legs does the medical service provider have on this dispute? They provide services to an 'in network' hospital and there are no other options at that hospital for their services. Can I claim that the medical service provider falls under the hospital's status with my insurance provider as 'in network' since the service provider has a contract with the hospital, and the hospital has a contract with my insurance provider? Are there any other options for me with the service provider before they send the disputed amount to a collection agency and report it on my credit?

4) This seems to be a widespread issue with PPO plans and 'in network' hospitals. I've done some initial searching but haven't found anything yet on it. I would think some consumer groups, lawmakers, or someone would have raised it as an issue by now. Any links, references, etc., that explore this issue with the insurance industry?

cut in half

ask three questions

leave out editorial comments
 

mtcutler

Junior Member
Just the facts

See original post. I edited to shorten and provide just the facts.

Any help is appreciated.
 

cbg

I'm a Northern Girl
1) Can BCBS claim the hospital is 'in network' when the majority of services provided there are 'out of network', and the patient has no choice once in the hospital who provides the services?

Yes. The hospital has signed a contract that THEIR charges will be in-network. They have no control over whether each and every other provider working within the hospital does likewise. The doctors etc. are free agents, most if not all with a private practice and not covered by the hospital's contract. The doctors have practicing privileges at the hospital but are not employed by the hospital, in most cases.

2) Can I go back to BCBS and get them to pay the above provider's outstanding bills, with the argument that BCBS approved it as 'in network' and therefore they must take care of this provider's disputed amount as well? They've already told me the difference is my responsibility, which I have not responded to yet.

You ARE responsible for the difference. BCBS is responsible only for the amount in their contract with the hospital. They've done you a favor in agreeing to treat the out of network providers as in network at all. The doctors, who have no contract with BCBS, have no obligation to accept BCBS's payments as final. What you and BCBS agreed to is between you; BCBS cannot require the doctors to accept the lower amount as final payment and they have no responsibility to pay those differences.

3) Can I claim that the provider falls under the hospital's status with BCBS as 'in network' since the service provider has a contract with the hospital, and the hospital has a contract with BCBS?

No. See above.

4) This seems to be a widespread issue with PPO plans and 'in network' hospitals. Any links, references, etc., that explore this issue with the insurance industry?

All I can tell you is that the insurance industry finds this just as frustrating as you do. They'd much prefer to be able to force all doctors in a participating hospital to be in-network but neither they nor the hospital can do so.
 

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