Patient payment responsibility

[mickibc]

What is the name of your state? Virginia

I have more than one situation that I do not know what to do about.

#1 My husband had a referral to a specialist. We made certain that the specialist was listed in the book of providers for our insurance. When my husband arrived for his appointment, he was seen by another physician in the practice. It turned out that this MD was not approved by our insurance. Shouldn't my husband have been informed of this at the time of his visit -- just how far is it the patient's responsibility to keep checking on who is approved? The MD's office chose to have him seen by a different MD, he did not have anything to do with this -- is one suposed to carry the list of approved MD's along at all times to make sure no one slips someone or something in that is not approved?

#2 A physician's office sent lab specimens to a lab that is not approved by our insurance. The office had all of the insurance info and I certainly had no involvement in their choice of labs -- shouldn't the MD's office be responsible for their error?

#3 The same MD's office submitted a charge for an item the insurance refused to pay -- the statement from the insurance company was that there was no patient responsibility for payment of any items on the billing. This MD is one of the approved MD's and has agreed to accept their payment but is billing me rather than arguing with the insurance company.

 

[JETX]

You can start more than one thread....

So, lets go:
"#1 Shouldn't my husband have been informed of this at the time of his visit -- just how far is it the patient's responsibility to keep checking on who is approved?"
*** I would check the facts here. It is my opinion that most times a 'practice or office' is part of a plan, not just the specific physicians. In any event, I would say it would be the patients responsibility to verify that a particular physician is in 'the plan', or at least to make it clear to the staff that a 'plan participant' was important/required.

"The MD's office chose to have him seen by a different MD, he did not have anything to do with this -- is one suposed to carry the list of approved MD's along at all times to make sure no one slips someone or something in that is not approved?"
*** Did he notify the staff of his requirement of the physician be a participant??

"#2 A physician's office sent lab specimens to a lab that is not approved by our insurance."
*** Again, was the staff instructed to send ONLY to a participating facility??

"The office had all of the insurance info and I certainly had no involvement in their choice of labs -- shouldn't the MD's office be responsible for their error?"
*** We don't know that this was an 'error'. It may be that your husband didn't stipulate to a particular facility.

"#3 The same MD's office submitted a charge for an item the insurance refused to pay -- the statement from the insurance company was that there was no patient responsibility for payment of any items on the billing. This MD is one of the approved MD's and has agreed to accept their payment but is billing me rather than arguing with the insurance company."
*** Something is CLEARLY wrong here. Did you get this 'statement' directly from the insurance company?? What did they say when you contact both the physician and the insurance company to try to resolve the contradiction??

 

[mickibc]

# 1. The MD my husband saw was not on the list and the insurance refused payment because of this -- the MD is billing us. My husband did not walk in stating he must see only aproved MD's -- he DID submit his HMO card which certainly indicates that the insurance would only pay for a particpating physcian -- and his appointment was with a participating physician. As you stated, usually a practice is approved rather than one MD in the practice -- if one goes to a practice and the office members have one seen by a different MD in the practice, it would be only a VERY reasonable assumption that this MD is also a particpating physcian.

#2. Again, this office had my HMO card and got its payment from my HMO and should have known to submit specimens to approved HMO labs -- this office is affiliated with a hospital OWNED by the insurance company.

#3. I can see the status of my caims on line and the insurance paid all but $100 of this claim and has a note saying "Deny claim - reconsidered - denial upheld. Provider responsible." It also clearly says "Patient responsibility $0.00" but I continue to be billed by the MD.

 

[cbg]

It has been my experience that while many practices do have all of the physicians participating in the same insurance plans, the insurance carrier cannot and some practices will not make it mandatory that ALL physicians sign the contract with ALL the same carriers. That is to say, while an insurance carrier could conceivably say, "Either all your doctors sign or we won't let you be part of the network" most of them don't - they'd rather sign up the doctors that are willing. Meanwhile, the practices COULD make it mandatory that all doctors sign with the same carriers, but don't. So what happens is that it IS the individual doctors, and not the practices, that are participatory.

1.) It is the responsibility of the patient make sure that s/he sees participating doctors. While you do not have to, as the poster puts it, carry a list of participating doctors in your pocket, if you get to an appointment and are told that you will be seeing a different doctor, it IS your responsibility to ask if that doctor is participating. (It is NOT the responsibility of the doctor's office to keep track of what plan you have and advise you if the doctor is non-participatory.) If you did not do so, it is up to you to pay any charges that are incurred because the doctor is not participating. If you DID do that, then it may be that the doctor's office will have to eat the excess, but you will have to enlist the help of the insurance carrier. Most of them have a department that provides such help - the carrier I worked for called it Provider Relations but another carrier may call it something different.

2.) Possibly, depending on the terms of the insurance contract, but not necessarily. This is another question that you will need to pose to the Provider Relations department. Your contract with the insurance carrier, the doctor's contract with the insurance carrier, AND the doctor's contract with the laboratory can affect this. As JETX says, it is not necessarily an error - it could be contractual or it could be that you did not specify that it should only be sent to a participating lab. One thing to keep in mind is that many carriers have multiple networks. Insurance Carrier ABC may have HMO, PPO and POS plans, all of which have different networks, at least insofar as laboratories and other fringe providers go. Multiply that by a dozen different carriers that the doctor's office may accept. There is no possible way that a doctor's staff can keep track of which laboratories, x-ray facilities, urgent care centers, etc. are participatory for each and every patient.

3.) Very, very definitely advise Provider Relations (or whatever your carrier calls it) that your doctor is balance billing you for an item the insurance carrier says you are not liable for. This is quite possible a violation of the doctor's contract with the carrier.

 

[mickibc]

Thank you for your help -- the following are more comments on the situation than questions.

Re my question#2 & the responses

A. If it is so totally unreasonable for an office to know which lab is approved by which insurance, why have I never been asked which lab my insurance uses?

B. Approved labs are not listed in my enrollment guide, on my ID card, nor are they available on the insurance Internet site -- if I'm suposed to know which labs are approved and to insist on them, I would think I should easily be able to find out the names of the labs.

C. The major employers in this area, as well as Medicare and Medicaid, all offer the choice of the same two HMO's (the employers also offer a third choice) therefore, it should not be so hard for the local providers to know the approved labs for these HMO's.

 

[cbg]

If there are no participating labs listed in your enrollment materials, then it is not outside the realm of possibility that there are no participating labs in your area. That does happen occasionally.