Jughead:
This is such a common problem. Even though a facility may be within your PPO network, it does not necessarily mean that all of the individual providers practicing there will be contracted with the same PPO network. Unfortunately, the ultimate answer to your question is that, yes, you can be held responsible for the higher amounts. The insured is ultimately the one to be responsible for being sure that all providers are within the PPO network. I do agree with you that this is not always very realistic in a situation such as yours.
I would first contact your Plan Administrator to ask if they might be willing to assign you a case manager to help you with this. In the case of the specialist, I would try to find out if the hospital had a specialist available within the network. If not, check the summary plan description (SPD) for provisions that allow a non-network provider to be paid in network. (Again, the Plan Administrator should be able to help you.) If no network specialist was available, it is likely you will be allowed the higher network level. A case manager could also likely help to negotiate post-service arrangements with the non-network providers to allow in network reimbursement.
If the Plan Administrator is not willing to assist, follow the guidelines in your SPD to appeal the decision. Follow all courses of action / appeal that the SPD allows. Be as thorough and complete in the information you supply as possible. You can also contact the providers to see if they would be willing to negotiate the rates if the PA does not assist. If your infant is still requiring medical services, become very involved in knowing exactly what services are going to be needed / provided and maintain contact with the Plan Administrator to help you find PPO providers.
Yours is an unfortunate situation and I am sorry it happened. Not to give false hope, but I have seen several of these situations successfully resolved when the Plan Administrator is willing to get involved.
Best of luck to you.
lkc15507
