Surgery was covered but anesthesia wasn't

[jglazner]

What is the name of your state (only U.S. law)? Colorado
We chose a surgeon and hospital covered by BCBS but they sent in an anesthesiologist who doesn't have a contract with BCBS. The claim was processed out of network and BCBS paid less than half. Do we have any recourse beyond sending a greivence to the insurance or do we have any recourse against the doctor for not informing us he wouldn't be covered?

 

[tranquility]

Be sure the Dr. is out-of-network by the rules. Many doctors in ER or sugery situations have out-of-state billing locations which (while I'm sure are for efficency only LOL) seem to get around capitation and contractual rates.

Write a letter to the insurance company and show that you chose the procedure done in a covered hospital, by a covered surgeon. Tell out the facts and ask for a review, or, if a denial has already been made, an appeal.

 

[ecmst12]

Anesthesiologists are pretty much never contracted, there is no incentive for them to do so. Your first step should be to CALL the insurance company and discuss with them; it could have been an oversight or other error. Of course it might not be, but every plan is going to handle the situation a little differently. If the outcome of the phone call is not to your liking, then start writing letters, just make sure you get the right names and addresses to write to, BCBS is a huge company.

 

[cbg]

Neither the hospital nor the insurance carrier can force the anesthesiologists to join the network. I can assure you that they would if they could - it does not benefit them for doctors in any department to be non-network. But they have no power to require any doctor in any department to join the network, and there are a few departments where the doctors realize that they will make more money if they do NOT join. Anesthesia is one of them. It may well have been a question of using a non-network anesthesiologist or not having an anesthesiologist at all. It's a shame but it's no one's fault.

And, as I have been saying for some time now, the insurance carrier is not required to violate their own policies.

 

[xylene]

Force anesthesiologist to sue you and you rob him of his profits.

Best you can do.

 

[tranquility]

Having been through this exact same situation (although not in CO, but CA) write a letter. If the answer does not come back within your time limit (I use 21 days) copy the letter to the Department of Insurance. They are not going to just agree with you. They are not going to even deal fairly with you. Write the letter and send the copy to the DOI. I've won so far, but am probably lucky as the reality is IMPOSSIBLE TO DETERMINE. It does seem like they don't like hassles as much as they like preliminary determinations. While I respect Emst12, I have NEVER gotten an acceptable response from a phone call.

Never.

 

[lkc15507]

Ancillary professionals may be employed by the facility in which case they would (most likely) be included in the insurer / provider contract. Or, they may be independent professionals, in which case they will choose for themselves which networks they contract with.

1) Some plans will address this situation specifically by allowing or disallowing the in-network status. Read the plan.
2) When not specifically addressed by the plan, an appeal, in writing, according to the plan's procedures is the first step. Timelines are described by the plan, not arbitrary. However, prior to blindly sending copies to DOI or whomever, first determine whether an ERISA or non-ERISA plan.
3) If ERISA send copies to the federal Department of Labor if you need or wish.
4) If non-ERISA send copies to your state's Department if Insurance if you need or wish.
5) Make a smart appeal in the first place. Read and understand all plan provisions regarding the availibility of network services. Find out if the facility had a network anesthetist/anesthesiologist available, whether pre-planned or emergent.
6) Refer to cbg's post. To reiterate what cbg posted, no plan must violate their own policies. I only add that that is true as long as those policies follow federal ERISA guidelines first, and state guidelines after, when applicable.

lkc15507

 

[momm2500]

look in your benefit plan booklet and see if your insurance has a clause that they will pay PPO or in-network benefits for an 'uncontrollable provider'. An anesthesiologist, a pathologist and a radiologist is usually considered under that tite of uncontrollable. meaning you can not control who comes in to do the service. if that is the case, either write or call your insurance company on this provision. if it is covered under this provision, then they will be up to their allowance for that procedure.

 

[SBillock]

It is also sometimes called a PAR (Pathology, Anesthesiology, Radiology) or PARE (Pathology, Anesthesiology, Radiology, Emergency Providers) agreement.