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$2K Medical bill - Assigned me out of network physical therapist

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Bali Hai Again

Active Member
This particular case sounds more like the providers office staff screwed up by not knowing the OON service would not be covered by OP’s insurance and told OP it would be covered. They then waited six months and sent the bill to saddle her/him with their screw up hoping she/he would forget. Telling the media that the system is corrupt won’t provide any value because everybody with half a brain knows it.
 


quincy

Senior Member
This particular case sounds more like the providers office staff screwed up by not knowing the OON service would not be covered by OP’s insurance and told OP it would be covered. They then waited six months and sent the bill to saddle her/him with their screw up hoping she/he would forget. Telling the media that the system is corrupt won’t provide any value because everybody with half a brain knows it.
Yes, but there are many many people in this country operating with less than half a brain. ;)

Following is a (probably not-very-relevant) article on the top 10 “winners” for the most egregious U.S. healthcare profiteers award. The complaint voiced in this thread are mild in comparison but still a disturbing look at one of the many failures in our country’s healthcare system. https://www.theguardian.com/us-news/2025/jan/07/annual-awards-healthcare-profiteering

Because a message repeated several times can eventually educate even those with brains reluctant to accept facts and truth, continued media coverage can be important.
 

LdiJ

Senior Member
Yes, but there are many many people in this country operating with less than half a brain. ;)

Following is a (probably not-very-relevant) article on the top 10 “winners” for the most egregious U.S. healthcare profiteers award. The complaint voiced in this thread are mild in comparison but still a disturbing look at one of the many failures in our country’s healthcare system. https://www.theguardian.com/us-news/2025/jan/07/annual-awards-healthcare-profiteering

Because a message repeated several times can eventually educate even those with brains reluctant to accept facts and truth, continued media coverage can be important.
Plus, the clinic (which is who made the mistake) is a much smaller organization who probably would suffer much more damage than the insurance company would if this became a local media issue. They might very well drop the issue with enough media scrutiny.
 

ChipParkr

Member
Have you specifically told them that you would not have utilized their services if you had known that they were assigning you to an out of network therapist?
Yes I had asked them twice over phone to confirm my insurance is accepted. When they told me there is no co-pay, I asked them again stating I dont want to see any bills later. They never told me at that time that theirs is an OON facility or I would be assigned a OON therapist. Even when I received my first EOB statement from Aetna, I took it to them and asked about it saying hope there is no issue here and all they said no worries we will give it to the billing department but you can continue the treatment sessions.
 

LdiJ

Senior Member
That was not my question. Have you told them, after you got the bill, that you would never have utilized their services if you had known that they were assigning you to an out of network therapist? Basically, have you conveyed those exact words to them? In a way, they have scammed you. You need to make that clear to them without actually accusing them of scamming you.
 

cbg

I'm a Northern Girl
While I am not defending the facility, which was careless no matter how you slice it, I do want to point out something that not everyone knows unless they work with health insurance (which I do, and have in one form or another for decades).

Every major insurance carrier has more than one network, and not all facilities are on all their networks. The major insurance carrier that my employer uses has 22 different networks covering our region, and that's omitting the dental and Medicare Supplement networks. The rate of overlap is probably in the high 80's if not the low 90's, but not all providers are on all networks. One of the things I have to do is make sure employees calling about their health plan options know which network to look at. Most of the plans we offer use (network A) but two of our plans offer (network B) and the student plans, which my office does not administer but which many of our new employees are coming off of, uses network C). This carrier is not at all unique. If I remember correctly, the major carrier that I worked for in the early 90's had 26 different networks.

At the same time, when there are facilities with multiple providers, not all of the providers have their contract with the insurance carrier renew at the same time, and the renewals do not all go smoothly. It is not impossible for any given in-network provider at any given in-network facility, to be temporarily out of network while the contract negotiations are going on.

It is not possible for the facility's receptionist, patient services, or billing office, to automatically know up front which network THIS patient's insurance plan uses, or the status of THAT provider with the plan in question. That's simply not information that they can keep in their heads. If 95% of providers are on 90% of the carrier's networks, and they're juggling the affairs of 25 different patients at the moment the patient in question asks, it's going to occasionally make a mistake. It's not deliberate, it's not malicious, it's not a coordinated plot to make this patient pay out of network rates; it's a mistake.

That is why it is imperative that instead of relying on the facility to say if they are in or out of network, the patient contact the health insurer DIRECTLY and confirm not only that Dr. Jones is in network, but that Dr. Jones is in network while practicing at the office at 123 Maple Street in Anytown. Get the name of the representative who answers and write it down along with the date and time of the call. That will give you much more protection in the event of an error, than relying on the doctor's office call.
 

Bali Hai Again

Active Member
I remember a time when health insurance was very simple. At one job the premiums were paid by the employer and the coverage was excellent. You signed up for health insurance end of story. There were no choices between HMO’s, PPO’s, in network or out of network BS nonsense. You got health insurance and it covered your medical costs end of story. Had three kids and didn’t pay a nickel to the hospital or doctors as well as all their medical bills growing up. The present system needs to be unscrewed and put back to the way it was.
 

paddywakk

Member
I remember a time when health insurance was very simple. At one job the premiums were paid by the employer and the coverage was excellent. You signed up for health insurance end of story. There were no choices between HMO’s, PPO’s, in network or out of network BS nonsense. You got health insurance and it covered your medical costs end of story. Had three kids and didn’t pay a nickel to the hospital or doctors as well as all their medical bills growing up. The present system needs to be unscrewed and put back to the way it was.
Wow, you were really lucky. I've never had such insurance. In fact, the first insurance coverage I had cost me $50 per month in 1975 to cover just me, the deductible per person was $1000 annually. and they meant per person. That's nearly a $6000 deductible in today's dollars. Worked for that nationally known company for 14 years and never had a dollar covered by that insurance.
 

cbg

I'm a Northern Girl
I absolutely agree that the system is broken. But the old indemnity plans were rarely that comprehensive.
 

quincy

Senior Member
Isn't there a law about surprise medical bills?? I remember hearing about providers giving patients quotes upfront.
Well, there was a “No Surprises Act” but whether it has survived the last two weeks of this new administration is a question mark. Because it benefits the consumer, it might have been executive-ordered out of existence.

Here is some information on the Act:

https://www.cms.gov/newsroom/fact-sheet/no-surprises-understand-your-rights-against-surprise-medical-bills

Oops. The CMS website has been eliminated.
 

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