med bill...doc not part of PPO

[Spe]

California.

I have full coverage via Blue Shield for 100% after $1,000 ded.
Sept 2001 had emergency surgery...hosp says covered by ins...good to go.

After 6 days in hosp and many chest x-rays and a CT scan, I am billed by XYZ Radiology Associates who say they are NOT part of hospital, but a seperate entity AND they are not Blue Shield providers, please pay us $900.00.

During 6 days in hosp, never once did they identify themselves as not being part of hospital, all I saw was an xray tech who came to room and took xray, never saw or met any dr. from this group, never informed me they were not part of my PPO.

After much time, Blue Shield paid me what Blue Shield said was "fair and reasonable" for XYZ Radiology Associates (about $170) I passed this moeny to the XYZ group. They still want more money, I said NO. They were paid what Blue Shield would pay if they were a provider, and that they would have to accept this payment the same way all the other medical providers accepted what Blue Shield paid.

They have sent bill to collection.

In my opinion they are unethical and running a pretty good "scam". They know they will not be paid as much by an insurance company, as they can squeeze out of most patients, no one going into this hospital knows that radiology will not bill any insurance to pay for xrays etc. And neither the hospital or these radiologists inform patients of this fact. When I informed my surgeon of this practice, he was astounded...I had informed him I would not use hospital for followup CT scan.

My contention is: I never "hired" them, they should have informed me that they were not members of Blue Shield, they had more than adequate time (6 days) to do so, and if I had been informed I would have demanded that service be provided by a member of my Blue Shield PPO.

Question: 1. What are my rights? 2. How do I get collection agency off my back and not have this dispute go on my credit report?



Steven

 

[cbg]

And how were they supposed to know who your insurance carrier was? That information is not available to every Tom, Dick and Harry working in the hospital.

This is unfortunately a common problem and there's not much anyone can do about it. There is no way an insurance carrier can force any entity to join their plan, and if the laboratory and x-ray departments are separate entities from the hospital, as is often the case, there is no legal way either the hospital or BCBS can make them join the PPO if they don't want to.

They don't know who your carrier is, so they can't notify you that they're not part of the network (even if it was their responsibility to do so, which it isn't).

Unless your state has some kind of regulation about this (for which information you call the state insurance commission) the only way to get them off your back is to pay the bill.

 

[Spe]

absurd logic

cbq---

your reply makes no sense...they need to bill someone when providing service, do you expect me to believe that they do not reference the insurance statues of a patient? Ever been to a doctors's office where they did not ask for your insurance information prior to treatment? How about an ER?


I would not consider a large, well-funded medical group that is providing radiology services in a 500 bed hospital to be just any "Tom, Dick or Harry" as you quote.

I doubt you have any expertise with which to answer my question, you sound very much like a layman to me...what are your qualifications?

Steven

 

[cbg]

I am a Human Resources Manager with 15+ years experience in benefits and five years working as a service representative with a national health insurance carrier, where among my day to day responsibilities was dealing with PRECISELY the issue you describe.

Are you telling me that you think the people who are on the floor doing patient care are the same ones who have immediate access to what insurance coverage each patient has? Are you not aware that the billing information, which is where the insurance information is maintained, is frequently done from a different location?

 

[vrzirn]

cbg is correct!
The radiology group is a private practice under contract to provide services to the hospital. Although you may have seen only the technician, I assure you the films were "read" by a real, live, radiologist.
You mention that this was an emergency surgery ; that meant a radiologist had to be on-call to review your films. It does not seem you were in a situation to "pick and choose". The Radiology Department sets it's own billing schedule and is not required to accept any plans if it does not wish to do so.
For all you know, another hospital may very well be served by the same Radiology group.
vrzirn M.D.