Out of Network payment

[ksedu]

What is the name of your state? What is the name of your state? NJ.

Hello,
Recently I received a bill from hospital where my wife was admitted for delivery. It turned out that the bill was for anesthesiologist who was not in the insurance network, adminstered medicine.

Now the insurance company has refused to pay for his fees since he is not in their network.

Insurance company says that we should check with each doctor whether he is covered in their network or not. That we do always whenever we take an appointment with any doctor. However, in this case we didn't call the anesthesiologist, he was called by the hospital staff and we were not even given a chance to find out if he is covered in the network or not. There are other anesthesiologist in the hospital who are covered in the network, we could have found out one in the network and requested for his/her service.

I feel like we have been tricked into this whole issue and now are being held responsible for his fees.

Any suggestions for getting our of this mess?

Thanks in advance,
ksedu

 

[Beth3]

Unfortunately, no. If the provider (anesthesiologist) is not in-network, then no discounted rate has been negotiated with that individual and consequently there are no cost-savings to pass along to you.

It's standard practice these days for many of these hospital-aligned providers to be independent service companies - emergency room doctors, radiologists, anesthesiologists, etc. and unfortunately, we as patients have no clue and often no choice in which service the hospital uses, even though we end up paying the bill.

The only possiblity I can see is if the PPO/insurance contract with the hospital specifies that they must use in-network providers for these independent S.C.'s when a member is receiving medical care, in which case the hospital messed up. I suggest you talk to the insurance company about that and see what they say. Ask to speak to the claims department manager - I doubt this is something the claims analyst can answer for you.

Odds are though that you will end up paying the anesthesia bill, subject to any deductibles and co-insurance that applies for out-of-network service. Sorry. I know it's frustrating as heck and it's happened to me too.

 

[lkc15507]

I absolutely agree with Beth. But, back to my same old rhetoric, check your insurance plan document. I have encountered plans that specifically address the issue of when a patient does not have a choice in the ancillary service providers. Claims adjudicators can and do make network mistakes. Failing that, it is always worth a try to follow your plan's appeals process.

Best to you,
lkc15507