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Natalie Z | Question about insurance coverage? |
I had non-elective surgery about 7 months ago. My insurance covers anesthesia for surgery as long as it's in-network. The medical office I visited was listed as an in-network provider for my insurance company.
I got the claim in the mail months ago from the insurance saying everything had been covered.
However, yesterday I got a bill in the mail from the doctors office charging me hundred of dollars for "anesthesia".
If the office I went to was "in-network", and did not disclose to me that I would be billed separately for anesthesia or disclose to me beforehand that the anesthesiologist was a not employed by their office directly and did not accept my insurance-
Is this legitimate? |
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sarah314
 |
Anesthesia is always billed separately.
It is possible for an anesthesiologist performing services at an in-network hospital to not be contracted with your insurance company. (They may be an "independent contractor" versus a hospital employee, and as such they would need their own separate contract with the insurance company.)
Your insurance company should pay out the same benefit level that they would pay to an in-network anesthesiologist. However, an in-network anesthesiologist would write off the difference between the allowed amount and their billed charges. A out-of-network anesthesiologist who doesn't have a contract with your insurance company is not obligated to write off the excess amount. This could be what you're being billed for.
If I were in your situation, here's what I would do...
1) Call the insurance company and find out whether the claim processed as "in-network." If not, they should adjust the claim to pay out the equivalent of your network benefits.
2) If the claim did pay as in-network, confirm with the anesthesiology practice that you're being balance billed. If so, ask them if they will negotiate the balance due with you. (You may find that they are willing to negotiate some of the balance bill amount...even though they aren't required to do so.)
3) If the insurance company has paid as "in-network" and won't pay anymore and you've don all the negotiating you can with the anesthesiologist, find out if you can set up a payment plan for the balance. |
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madjackolantern
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if you had pre approval for the surgery there should be no anesthesia bill. even if the actual provider is not in your network, the hospital knows this and it is not your responsibility. call your insurance company and have them deal with the bill. |
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Katherine K
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Hey there Natalie,
Certain types of physicians at in-network hospitals are NEVER going to be in-network. The simple answer is that they believe their time is worth exactly what they're billing for it. Since anesthesiologists are the one who give you the drugs, you certainly want them there at the time of surgery.
If you have an in-network benefit of 80%/20% (meaning that your carrier plays 80% and you pay 20%) what will happen is that you need to contact your health insurance plan and have them process the claim at the in-network coinsurance level.
Because these doctor's don't have a contracted rate discount amount that they write off, you should still only be responsible for the 20% but you'll be responsible for 20% of the ENTIRE bill, not 20% of the negotiated rate. That's the best that you're going to be able to, and the good news is that you're going to get credit for the 20% of the entire bill towards your out-of-pocket maximum which will lower your future liability for claims later in the year.
I hope that answer your questions. Let me know if you need anymore info.
Good luck!
Kathy K
www.premiumwatchdog.com |
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MzAnndiva
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Hi, I hope all is well with you and glad your surgery was a success. In regards to your question, the anesthesia should be covered and what you need to do is contact your insurance company and verify that a claim for that bill mailed to you was submitted to your insurance company... If the anesthesia bill was not sent to the ins company then it would need to be. If your insurance company denied the anesthesia claim and that's why they sent you the bill you will still need to find out from the ins company why it was denied... If the insurance company rep stutters or seems as if he or she doesn't know what they are talking about - ask for a supervisor and demand the claim be paid via single case agreement or just for courtesy because you can't choose your anesthesiologist and they are billling you and you don't want that issue on your credit.
Hope this helps. Mzz Ann |
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Zarnev
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It is both legitimate and legal. Not every professional in a hospital, clinic or doctors office is in network just because the main provider is. However, you said the insurance company said everything was covered - was the anesthesiologist included in the paperwork? You need to check to make sure the claim was filed. The information you get from the insurance company will say it's either covered or not covered so if nothing was there the claim may not have been filed. If that's the case you can discuss this with the provider to find out why it wasn't filed in a timely matter and most of the time if you persist they'll eat the cost. Also, some insurance plans will cover out of network so if this is the case you can file with the insurance company yourself. |
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mbrcatz
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OK, if the hospital was in network, their staff anesthesiologist should be billed as in network.
If your insurance DID pay this as in network, you need to call them, and have them adjust it. If they paid as out of network, you need to call them, and have them pay it as in network.
It's common for the provider to bill you for the difference, and for you to have to call to get the balance waived off.
It doesn't sound like anything illegitimate is going on here . . . just a massive case of miscommunication. But it's going to require some legwork from you to straighten it out. |
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tngandhkm
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Anesthesiology is generally always billed separately as it is a separate professional service provided. Just like the surgeon bills separately, the hospital bills separately, etc. Unless the anesthesiologist is an employee of the hospital, they are a independent contractors of the facility and may not be contracted with your insurance company. Unfortunately, it's not the hospital or clinic's responsibility to know your insurance policy and who is and out of network, that is your responsibility. I don't mean to sound flip about it, but that's how the insurance industry works. The onus is on the patient to know if a provider is in or out of network. There is an interesting article discussing this -- with anesthesiologists as the example -- here http://goliath.ecnext.com/coms2/gi_0199-3149106/Some-hospital-docs-don-t.html
Some employees of area companies who have gone to the hospital for tests or surgery are feeling a different kind of discomfort when they open the bills.
Instead of being charged the preferred provider organization (PPO) rate of a few hundred dollars or less of for the services hospital-based specialists, they're finding they owe anywhere from $5,000 to $15,000 because the services fell outside of their PPO network.
They mistakenly assumed that if a hospital was in their network, any physician who treated them at the hospital would automatically be covered. But doctors who are usually independent contractors-such as anesthesiologists, radiologists, emergency physicians and pathologists-aren't always signed onto the same networks as the hospital.
Insurers, hospitals and doctors agree that surprise out-of-network charges are a serious concern, but each group points to another one as the culprit. |
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debijs
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~~It iis sad but true, you are ultimately resposible for using the provider network. It's really hard for people to get all the information gathered when they are in a medical crisis, but that is what insurance expects us to do. You will be responsible for this bill.~~ |
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Rajesh K
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it is not legitimate,they have to explain eveything in advance,you have communicate your concern to insurance company |
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