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PPO- Network Outpatient facility uses Non-Network Pathologist

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littlebird024

Junior Member
What is the name of your state (only U.S. law)? Michigan
What can you do when a Network Physician, who performed a procedure on you at a Network Outpatient facility, and all ancillaries were also IN network with the exception of "Pathology". At registration, I verified that this was a network facility. Now I'm getting billed for Non network pathology procedures...I would have never gone to this facility knowing this. Is there anything I can do?
 


justalayman

Senior Member
after the fact: not much other than complaining to the facility for failing to warn you that the providers of ancillary services may not be "in network".


Ultimately it is your responsibility to ensure all providers are in your network. I understand, and even sympathize with your situation. It is not uncommon. I have not found a means to totally ensure all providers used will be "in network" myself.
 

cbg

I'm a Northern Girl
Believe me, both the hospital and the insurance carrier would love it if they could force the pathologist to be in network. The pathologist has free will and can choose to participate or not participate. I doubt there is a hospital out there that can guarantee that all the doctors and services working for them are going to be in network for any given plan.

Certain specialities, pathology among them (anesthesia, emergency care and radiology being others) have decided that they can earn more as an out of network provide than they can as an in-network provider. They figure that they have what is more or less a captive audience and being in-network gains them nothing - particularly since few of them have any kind of private practice (unlike an internist or a plastic surgeon or even a dermatologist). And with very rare exceptions, all of which relate to the way they are contracted to the hospital, it's entirely their choice.

All you can do is request that as often as possible all providers that are used be in network, and accept that the nature of the beast is that occasionally it won't be possible. And when it isn't, pay your bill. Yes, you have to. No, you can't force the referring provider to pay it. No, the law won't force the insurance company to pay it. No, you don't get to leave the bill unpaid.

You see, I've been asked this question a few thousand times before....
 

ecmst12

Senior Member
Pathologists are almost never in-network with anyone, so there is almost never an option for an in-network pathologist.

I would call your insurance company and ask them to consider the bill as in-network since the facility and the doctor were in-network.
 

cbg

I'm a Northern Girl
Agree with ecmst12 with one caveat:

Even if the insurance company agrees to consider it as in-network, that does not mean that they are guaranteed going to pay the bill in full. The example below uses numbers designed for easy arithmetic and are as an example only, but this IS how it works:

Let's say the bill is for $250. Let's also say that the in-network rate is $200; i.e. an in-network provider under that plan would receive $200 as full payment for these charges. EVEN IF the insurance company agrees to consider the bill as in-network (and they might - no harm in trying), the most they would then pay is $200. If the out of network provider then decided to come back and charge you the additional $50, there is nothing to stop him from doing so.
 

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