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pandabunny | Insurance B.S.? |
I found a provider on my insurance's plan, and now that provider is no longer on the plan for whatever reason. In the meantime, I have been billed full amount for out-of-network. ($1000 or so)
Who would I try to get to pay me back? My insurance company or the hospital? Or am I screwed? My instinct tells me I have no chance of getting out of this bill, even though they were on the plan before. I can't prove anything because the name was on the website, and now it's not there. :( |
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nurse ratchet
|
OK, first of all, it is always your responsibility to make sure you are using a PPO provider. They are added and deleted all the time. The people that should have told you was the provider (doctor's office or hospital) themselves. When you went to their office and gave your medical ID card to them, they should have informed you they had dropped from that provider listing and you would now get non-PPO (reduced) benefits. However, they are not required to tell you. I would go to them and explain that you were using them because you thought they were on your PPO network, and ask them to accept PPO fees as payment in full. They should at least reduce your charges to what your PPO network negotiated the fees down to. You should be able to negotiate the bill down with them. I hate when this stuff happens to my clients, and it happens a lot, too. |
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Tally
|
Contact your insurance company. I'm surprised they wouldn't at least pay 70% or so. Just call and explain what happened...even worst case scenario you'd be told you'll have to pay it all. |
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Custo
|
Most of the provider lists on an insurance company's website is as up to date as the company's actual database. It is usually as up to date as possible. How long after you checked their website did you go to the hospital? If it was a pretty short amount of time, you should be able to appeal through your insurance. company and have it paid... If it was a long period of time, your chances of having it overturned are slimmer. Some insurance plans make you appeal in writing, others will let you appeal verbally. If you have to appeal in writing, just state you wish to appeal their decision to process your claim out of network, and why. In your case, indicate you checked your provider directory and the hospital went along with it... There are exceptions to every rule. They'll probably decide in your favor, and pay the claim. I'd also check to see when the hospital's contract with your insurance ended... Not having 'proof' is irrelevant if they can verify the term date of the hospital's contract... Good luck. |
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withluv7
|
The insurance company and the provider are responsible for telling you that he was no longer in network. Being in network and out of network is a contractual thing between provider and insurance and if you were an EXISTING patient you do NOT h ave to pay for out-of-network if the provider did not let you know that he was no longer participating. |
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HC Investigator
 |
call the provider network or insurance company and clarify when the provider dropped from the network. his name would not be in there unless he was a participating provider at one time. make sure you did not inadvertingly look up the wrong network information. sometimes the network has carve outs for areas that may not pertain to you. it is possible you accessed the wrong information and if you did, then that would be your error. the best bet is to always call to confirm the provider's participating status with the network. I would not rely on books or websites. |
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The Rabbi
|
Any provider is going to check your coverage before providing service unless it is an emergency, in which case ins. takes care of it.
Your provider was responsible to tell you that you were out of network.
It sounds like you are really confused. Call the ins. co. They are very friendly and will help you understand. You haven't provided enough information here.
If you find out that it was all your error, negotiate with the provider and make them feel guilty. |
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Frankly Frank
|
Call you insurance company and verify that the provider was at one time a "participating" provider, get the dates. They should have a start date and the date the resigned. Did you do business with them while they were participating? If so, get your insurance company to send you copies of the EOB's.
Contact the provider and make your case (in writing and by phone). If they won't budge, call your attorney general and you states insurance commissioner. Each state has its own insurance commissioner, make a report to them. Most of the time they are on your side and can make things happen.
Good luck. |
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Mandy W
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I would try your insurance company and if they don't pay take it to your state insurance commissioner. Your company should have notified you if they changed providers. |
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