Dr.'s office messed up--do I have to pay? PPO

[dncr]

Hi, I live in California. Sorry for the length of this...

Last October, I was sick and needed to see a doctor. I have a PPO (Cigna), so I don't have a primary care physician--I can go to anyone in the network. The doctor I wanted (and knew was in my network) wasn't available that day (they never are), so I asked who WAS available. The appointment-taker asked what my insurance was, and I told her. She said, "I have an opening with Dr. so-and-so at such-and-such time" I said, "I'll take it."

A month or so later, I got a bill from the doctor's office, because the Insurance company declined it. After a couple of phone calls, I got a letter from the insurance company saying that the doctor I had seen was not an in-network doctor.

I called the billing office of the doctor, who told me that it's my responsibility to know which doctors are in-network and which aren't. I called the doctor's office and spoke with the supervisor over the appointment takers, and he confirmed that.

My point is, if I say "I have Cigna PPO. Who do you have available?", and they make me an appointment, isn't it a reasonable assumption for me to take that they would give me a doctor who takes that insurance? If they don't know whether the doctor is in my network or not because they can't keep track of it, shouldn't they say something like "I have so-and-so available, is he in your network?" or "you need to make sure he's in your network." I keep getting told, "you have the directory, don't you?" Well, sure, I was given one like three years ago. How often do they get updated? How do I know this doctor wasn't added after that directory was printed...how do I know that the Dr.'s office doesn't know what insurance each one takes if they don't tell me that?

What should I do at this point? The insurance plan administrator at work says I'm stuck, as does the doctor's office. I can call the insurance company, but I doubt they'll do anything. Any advice would be great!

 

[cbg]

You aren't going to like my answer, so I'm going to give you my qualifications first. I am an HR Manager, with over 15 years experience in Benefits. For a five year interim during the 90's I worked for a national health insurance carrier, which at that time specialized in PPO's, as a Service Representative. You would recognize the name of the carrier if I told you. (it was not Cigna, but they all work pretty much the same way.) Part of my job was to answer questions like yours.

A PPO plan allows you to go to ANY doctor, whether they are in the network or not. However, they only pay in-network benefits for in-network doctors. I'm willing to bet that your EOB said the charges were applied to your deductible, rather than declined outright.

Because the plan is specifically designed for you to be able to access out of network providers if you so choose, it is your responsibility to verify that the doctors you see are in the network. For an HMO plan, where there are no network doctors permitted except in an emergency, or for a POS plan, where out of network doctors have to be referred by a PCP, the doctor's office holds the ultimate responsibility. But on a PPO plan, since you have the freedom to choose to go out of network without a referral, you also have the responsibility of checking.

I understand the point you are making, but the doctor's office cannot guess what is in your mind. Simply announcing who your insurance carrier is, does not tell them that you ONLY want to see in-network doctors. When they said they had an appointment available with so and so, you needed to say, "Is so-and-so in the CIGNA network?" While it is true that the doctor might have joined the plan after the directory you have was printed, first of all the doctor's office doesn't know when you received your directory (for all they know, you got a new one last week) and secondly, just about all insurance carriers update their doctor directories on their website monthly, if not weekly, if not daily. Or, for all they know, you didn't care whether they were in-network or not, as long as you got seen immediately.

About all you can do at this point is call the insurance carrier, explain what happened, and throw yourself on their mercy. While under the plan they do not have to, it's always possible they may decide to make an exception.

 

[dncr]

What a bunch of BS. Sorry, not you or your answer, but the system. If I give my insurance info and ask for a doctor, I should be given a doctor who takes my insurance and told if the doctor is not in-network. If the appointment-taker has no way of knowing whether he's in-network or not, she should mention that. Would it be so hard to say, "I have so-and-so available, but he's not in-network. Is that ok?" or "you might want to make sure he's in your network." As you know, insurance is one of the most complicated things out there. I'm a reasonably intelligent person, and I have never heard of being given a doctor that doesn't take your insurance (putting the responsibility of double-checking that on the patient without mentioning it), and neither has anyone I've discussed this with.

And yes, they applied it to my $200 deductible, but that really doesn't do me any good, because I have never gone outside of the network for care.

 

[cbg]

I can see both sides.

On the one hand, it's true that even people who work with insurance find it confusing, and people who don't deal with it on a regular basis need some guidance.

On the other hand, it's also true that even within a certain carrier, a doctor might be in network for some plans and out of network for others; for example, it's not unusual for a doctor to be in network for HMO's and POS plans, but not for PPOs, or in for PPO's and not for the gatekeeper plans, or in for POS and PPO but not for HMO's etc. And within each category, there will be several products, so, for example, Dr. A can be in network for Cigna's plan # 1, 3, 5, 6 & 7, and out of network for 2, 4, 8 & 9. Multiply that by the number of doctors in the office, and then multiply it again by Aetna, BCBS, United Healthcare, Principle, Unum, Kaiser, Anthem, and whatever local or regional carrier may be in your area, and expecting the provider's office to always have 100% responsibility to tell any given patient whether the doctor in question is in network for THEIR insurance plan, seems a bit unfair.

 

[dncr]

Right, and as I keep saying to anyone who will listen, I understand (now) that they can't know all the plans all the doctors participate in, but they should give that caveat when making the appointment.

I'll give an example: I'm a customer service rep for a mutual fund company. Certain share classes have a back-end sales charge (redemption fee) if the shares are sold within 18 months. It says this in the prospectus, which is provided to the shareholder when they purchase the shares. They're supposed to read the prospectus. Do they? no. Anyway, when they sell the shares within 18 months, we're supposed to remind them of the fee, along with several other things. They're supposed to know that stuff, but we don't expect them to, so we tell them. If we don't, we get in trouble. We've had to make special accommodations for shareholders because the rep they spoke to didn't give the proper caveats reminding them of things they were given in the prospectus.

It all comes down to reasonable expectations.