Insurance did not pay at in-network levels for Emergency?

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Insurance did not pay at in-network levels for Emergency?

I was in the hospital for 5 days from a severe asthma attack. Was unconscious for the first 2 days and in ICU.
The hospital was "in-network" as well as the emergency room part of the bill. Bills exceeded my "out of pocket max" ($2000) and I have paid these off. The last bill I received was from the doctor in ICU, it was indicated on the bill that my insurance is paying only a small portion due to the fact it was an "out of network" doctor. The bill for this was $3500. My portion was going to be around $2000.
The insurance book shows that "Emergencies are paid at in-network levels even when an "out of network" doctor is used. I am trying to appeal, but from the initial phone call it did not seem to be too promising. Anyone have an idea about what to do ?

Suzanne: YPA

Typically, these policies will only pay at the in-network rate for emergency care rendered in the ER; once you're moved to another Unit within the hospital, the policy will pay non-participating providers at the out-of-network rate. (Please note that all doctors working at a hospital are NOT considered "staff doctors." Many doctors, such as ER physicians, plastic surgeons, and "Intensivists" working in ICU's, are employed by private practices that don't participate with the hospital where they work.) I suggest you carefully read the policy's definition of "Emergency care" to check into this.

FYI, even if you're able to get the insurer to pay at the in-network rate, you'll still be responsible for the balance of the bill since the non-participating provider is not required to accept the insurer's payment as payment in full.

If you need help appealing this matter, I suggest you contact your state's insurance commissioner's office. All state insurance commissioners have special units that do this for consumers.

sarah314

Suzanne got it right...

The insurer has to pay the out-of-network doctor the same reimbursement that they'd offer an in-network doctor. If they did that, then they've held up their end of the bargain.

However, unfortunately, the out-of-network doctor is not required to accept that as payment in full. They can balance bill you for any difference in their billed charge vs. the rate the insurer offers network providers.

Since you're indicating that the original bill was $3500 and you're being billed for around $2000, I'm presuming that its a balance bill situation. (The numbers you gave would put the insurer at paying out around $1500 to the provider, which sounds like it could be a network rate.)

If you're being balance billed, you're liable for the charges. Unless you can convince the out of network doctor to accept the in-network rate and not balance bill you.

(I know that can be confusing for some people - the difference between being balance billed vs. the doctor being paid out of network. But, it is what it is.)

Barry auh2o

Out of network doctors do not have to accept "in network" payments as payment in full.
Call the doctor and try to negotiate a lower fee. Explain this is what your network will pay, and could he discount his fee???

mbrcatz

You need to contest this in writing, with your insurance company.

A staff doctor in an in network faciliity should be paid as an in network doctor.

Phone calls mean NOTHING. You have to appeal in writing. Keep a copy of the letter, and send it certified.

bud68

mbrcatz1 is so correct: phone calls and e-mails mean nothing. All communication with your insurer has to be in writing via certified mail.

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