Help! insurance wont pay

[nanomug]

What is the name of your state? california
We took our son to the emergency room at an "in network" hospital due to a fever of 105. The insurance paid for the hospital bill, but not the full er doctor's bill as the er doctor was "out of network". This leaves close to $500 that we owe the er doctor after the "usual and customary" payment was made by the insurance company. The insurance company says it doesn't negotiate with out of network providers. I thought they should pay/resolve this since we went to an in network hospital.
It doesn't seem right that we went to an in network provider and then have to pay a huge bill. Is there any recourse with the insurance company?

 

[cbg]

You can appeal, but frankly you don't have much hope of winning.

Here's the problem, and I guarantee you that the insurance carrier is just as frustrated by it as you are.

The hospital may be in-network, but that only counts for the HOSPITAL bills. The doctors are, in most cases, not employees of the hospital but independent practitioners whom the hospital has granted privileges to. In many if not most cases they have independent practices outside the hospital and work x number of hours or shifts keeping the hospital manned.

Because they are not employed by the hospital directly, they are not covered under any network contract the hospital may sign. They have to sign their own contract with the insurance carrier. The hospital cannot force them to sign with every insurance carrier they work with, and the insurance carriers cannot force them to sign either. If the doctor chooses not to sign with any particular carrier, they cannot be forced to do so. I assure you that the insurance carrier would LOVE to force all the doctors in an in-network hospital to sign with them, but they cannot do so legally. The doctors have free will and if they'd rather bill the patients directly, they can. Some doctor's, particularly anesthesiologists and ER doctors, feel that they have a "captive audience" and make the decision to remain out of network. Since the doctors have not signed a contract with the insurance carrier, the insurance carriers cannot force them to abide by the payment limits that the hospital does.

 

[jwmc736]

It's possible that your insurance company could consider your charges "ancillary". This means that if you go to an in-network hospital but they utilize an out-of-network pathologist, anesthesiologist, etc. that those charges are considered "in-network". It doesn't mean that you'll get the PPO or HMO rate--it'll still be subject to reasonable and customary cuts--but at the very least, perhaps the allowable charges won't be applied to your deductible.