Doctors office pretends to be Aetna HMO member - then charged me as cash pay!!

[Dadhuntfish]

I live in Oklahoma and have just been stuck with $2,500 in medical expenses - and I have excellent insurance!! My mother recommended an orthopaedic surgeon to look at my failing knee. I went through the proper procedure of having my primary care physician (PCP) provide a referral to their office. I assumed that they did the pre-authorization as well since I had an appointment scheduled with them through my PCP. When I arrived at the office they asked for my insurance card and the other basic info. They said everything was in order and I saw the doctor. We agreed to a therapy that required me to get a series of injections in my knee over the course of five weeks. At each visit I checked in as normal and afterwards I paid my $10 insurance co-pay. After several weeks I started to receive bills from their office that showed my balance, co-pays and also that they had filed with the insurance company. Basically everything looked in order. I went back to this physician 2 months later because the therapy had failed to provide any relief (the bills still looked the same at this point). When I arrived at the office this time to check in for the appointment they asked me if I was going to pay in cash. I explained that they had my insurance information as I was a current patient. She said if I still had Aetna they couldn't see me because they do not accept that insurance. It turns out they have never been aetna member physicians. I asked them why I was not informed of this prior to my first visit and got an 'I don't know response'. They then told me I had always been set up as cash pay. I asked them why they had accepted insurance co-pays on each visit and why the bills showed insurance had been billed. Still no answers - the only answer I am getting is pay the bill or we turn it over for collection. This sounds like fraud to me. I never agreed to be a cash pay customer. Do I have any recourse at all.

 

[cbg]

Very important question; did you at any time ask them if they were a participating provider with Aetna?

When I was working with a national health insurance carrier (and no, it was not Aetna) a number of people made two major errors; 1.) they assumed that if their primary care physician made the referral it was covered in network regardless and 2.) they asked the question using these words: "Do you accept (in your case, Aetna) insurance? The answer would be, yes, meaning that if Aetna sent them a check they'd cash it.

Did you make either of these errors? I'm not saying it's hopeless if you did; it's just that my response as to the action you should take will be different depending on your answers.

 

[Dadhuntfish]

Very important question; did you at any time ask them if they were a participating provider with Aetna?

When I was working with a national health insurance carrier (and no, it was not Aetna) a number of people made two major errors; 1.) they assumed that if their primary care physician made the referral it was covered in network regardless and 2.) they asked the question using these words: "Do you accept (in your case, Aetna) insurance? The answer would be, yes, meaning that if Aetna sent them a check they'd cash it.

Did you make either of these errors? I'm not saying it's hopeless if you did; it's just that my response as to the action you should take will be different depending on your answers.

Yes, I asked the girl at the check-in when I gave her my card if they accepted the insurance. She said yes and also noted on my card that I had a $10 co-pay. I assume this is why they continued to see me and only request the co-pay amount at each visit.

 

[cbg]

Okay, your first step is to go back to your primary care physician and ask why you were referred to this doctor when he/she is non-participating. I'm not saying this will positively get you out of having to pay the balances but it's the first step. Also, go back to your plan document and find out what it says about referrals to non-par practicioners. When you've done that, come back and I'll take you on the next step, whatever it might be.