In-network provider refuses to accept negotiated rate

[gauss]

When I have had trouble with in network providers balancing billing me, I did the following with success.

#1) Attempt to verify if provider is In Network by researching on Insurance co's web site

#2) Call insurance company and ask if this is correct (ie the balance billing for In Network providers).

#3) Wait on hold while Insurance CSR contacts providers office and discusses/reminds them of the terms of their contract (at least that is my assumption of what the conversation is about).

#4) CSR comes back and tells me that the issue has been resolved. I confirm with the Ins co CSR that this means $0 balance.

#5) I contact the provider by telephone (from telephone number listed on bill) a few days later to inquire what my current balance is. Usually reports as 0 by now. If not, repeat parts of the process until balance is 0.

This process has not been too aggravating or stressful (outside of receiving the initial bill.)

The fact that we have a fairly dominant incumbent carrier (who's name starts with a word that rhymes with Clue..) in my area probably helps in this regard.

-gauss

[Mulligan]

Quote:

Originally Posted by EastWest Gal Also we should know the price up front. I'm a doctor and the price our company charged varied depending on the insurance. It's a ridiculous system. Sent from my iPhone using Early Retirement Forum

You mean to actually tell me EW Girl that your initial enthusiasm for entering this profession wasn't based on the excitement of dealing with medical coding, office workers, insurance haggling, and collection processes?


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[SJ1_]

Quote:

Originally Posted by Disappointed I would do all 1-4. 5. Something else? Sent from my iPad using Early Retirement Forum

If 1,2, and 3 do not work.

Take them to small claims court. It would cost them a lot more than $142 to defend themselves.

[2B]

Quote:

Originally Posted by EastWest Gal Also we should know the price up front. I'm a doctor and the price our company charged varied depending on the insurance. It's a ridiculous system. Sent from my iPhone using Early Retirement Forum

I can't remember where I saw it but it was a comparison of how getting your brakes worked on if we had "brake insurance" just like our health insurance. It went something like below:

You have to find an "in network" brake repairman but you have to be careful to make sure they work in an "in network" repair shop. The actual brake job costs $17,000 but your negotiated brake job rate is $2,000. Your copay is $500 as long as everything is "in network." This, of course, doesn't include any machine work done on your brake drums which if done "in network" will cost $100 copay. If not "in network" it will be whatever they charge. The repairman is not familiar enough with your insurance to know if the machine shop is "in network" and resents you wasting their time asking about it. Any parts are also extra and you will find out what they are when the final bill arrives.

It's a good thing you have brake insurance that only costs $500/year or you would have paid over $25,000 for the brake job that only cost you $2,600.

[gauss]

Quote:

Originally Posted by SJ1_ If 1,2, and 3 do not work. Take them to small claims court. It would cost them a lot more than $142 to defend themselves.

Question, assuming that there is some type of state law that bans balance billing in the jurisdiction, would a small claims court be willing to invalidate the contract between the patient & the provider due to it being unenforceable or do small claims courts just interpret the terms of the contract as written?

If there is no law banning this, could you even bring a case? I would think that other contracts the provider has entered into (ie with Ins Co.) would be irrelevant, but I am obviously no attorney.

-gauss

[rbmrtn]

Texas has rules against balance billing, State Restriction Against Providers Balance Billing Managed Care Enrollees | The Henry J. Kaiser Family Foundation

Something sure doesn't sound right. If you say you signed some waiver for the negotiated rates then they may have you. But it sounds like they have violated their contract with the insurance to be a "network provider"

[youbet]

Quote:

Originally Posted by gauss When I have had trouble with in network providers balancing billing me, I did the following with success. #1) Attempt to verify if provider is In Network by researching on Insurance co's web site #2) Call insurance company and ask if this is correct (ie the balance billing for In Network providers). #3) Wait on hold while Insurance CSR contacts providers office and discusses/reminds them of the terms of their contract (at least that is my assumption of what the conversation is about). #4) CSR comes back and tells me that the issue has been resolved. I confirm with the Ins co CSR that this means $0 balance. #5) I contact the provider by telephone (from telephone number listed on bill) a few days later to inquire what my current balance is. Usually reports as 0 by now. If not, repeat parts of the process until balance is 0. This process has not been too aggravating or stressful (outside of receiving the initial bill.) The fact that we have a fairly dominant incumbent carrier (who's name starts with a word that rhymes with Clue..) in my area probably helps in this regard. -gauss

I like your system gauss. But, OP has the complication that he's not just trying to get a bill balance reduced to zero, he's trying to get a refund of money already paid. Doc's billing dept knows that just stalling on this is to their benefit.

[youbet]

I have an expensive, no deductible, no co-pay Medicare Supplement plan. I think I could actually save money by going to a plan with lower premiums but with a deductible or co-pay. But my plan allows me to avoid the stress and aggravation that OP is going through. I never get services outside of network or where I have to pay in advance. And my bill is always zero.

In 2014, the deductibles I saved did not make up for the higher premiums. I don't care. I don't want bills. I don't want negotiations. I just have the premium auto-deducted from the checking account and try not to think about it. It's part of my desired FIRE lifestyle.

It says something about our medical system I guess if a frugal guy like me is willing to pay more just to avoid dealing with the billing and tracking and general hassles.......

[rbmrtn]

Quote:

Originally Posted by 2B I can't remember where I saw it but it was a comparison of how getting your brakes worked on if we had "brake insurance" just like our health insurance. It went something like below:

I remember one , if airlines were like healthcare

https://www.youtube.com/watch?v=uXyp3BW5QII

[Lakewood90712]

The OP stated , during a conf. call with the insurance co and provider , OP was told that a 'Waiver" was signed by the OP at the provider, and so far , the provider has not provided a copy. If true, the OP is SOL. I think this is unfair , but probably legal.

The "Negotiated" rate. Nobody but a mega size medical group or a hospital has any negotiation leverage with the insurance co's. It's take it or leave it. The mega size medical groups and hospitals can use this , agreeing to take a loss on some things, making it up hidden elsewhere. A small practice is clearly stuck.

[iac1003]

It's really hard to get the actual rates from the insurance companies before signing on as a provider in-network. But I can't imagine how, if they are in-network, they can get away with having patients sign waivers such as this.

Do you have any friends/relatives who are lawyers? A well-placed attorney's letter (for free) to the doctor might get his/her attention and get you a refund.

Once you get the money back, report this practice to the insurance company and ask that they be terminated from being an in-network provider.

If this is such a common lab test why does it need to be done at an MD's office? Could it be done at a freestanding lab (unless it was an special xray, bone density or some other test)? Did the doctor have to interpret the test? That would be a separate cost. I am confused.

(Soon to be retired psychiatrist.)


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[Katsmeow]

Quote:

Originally Posted by youbet I have an expensive, no deductible, no co-pay Medicare Supplement plan. I think I could actually save money by going to a plan with lower premiums but with a deductible or co-pay. But my plan allows me to avoid the stress and aggravation that OP is going through. I never get services outside of network or where I have to pay in advance. And my bill is always zero.

Same reason DH has such a Medicare Supplement plan....and yet...

Just yesterday we got a bill from a provider who has seen him before and does, indeed, take Medicare. He had received the same bill, last month. So, DH politely called them and reminded them that he has Medicare and they verified that the did indeed have his Medicare Information and his Medicare Supplement information. He was told to ignore the bill and they would submit it.

But...then yesterday he gets the bill again. So, he calls again. Same response - ignore it and we will file it. He asked when and she said she was doing it right then. He asked if they had filed it after his last call and she said she could find no sign that they had.....

So, even having that Supplement doesn't always prevent problems.....

[soupcxan]

They emailed me a copy of what I signed. In tiny print at the bottom of the boilerplate it says:

Should I file this with my insurance on my own, I release [doctors office] from any financial adjustment to the prices listed above.

So they've won this round. But I filed a complaint with my insurer before I received this, so hopefully they will give them some grief anyway.

[iac1003]

That statement means they think they are out of network. They are using deceptive practices as they verbally told you they don't bill the insurance company. That is not legal if they are in network. If they are in network they MUST accept the negotiated rate. It's part of their contract. They can't balance bill you.

Please speak with someone in a supervisory position at your insurance company. It doesn't matter if you sent it to the insurance company or they did. Fax the insurance company the statement at the bottom of the form the doctor's office sent you - it isn't really legal. They should throw this doctor off their panel. Which s/he probably doesn't mind.

I had a problem with an insurance company considering an in-network hospital out of network and I found out who the CEO and the CFO of the insurance company were and wrote them a more than pointed letter, but that's another issue. They billed as in-network after my letter.

Next time you are sent to a specialist please know especially if an HMO they should be doing all billing. If they are asking for $ up front more than your copay something is very fishy.

I'm sorry this happened to you.

Consider suing in small claims court. I'm serious.

This just makes me mad - and I'm an MD.


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[rbmrtn]

Quote:

Originally Posted by soupcxan They emailed me a copy of what I signed. In tiny print at the bottom of the boilerplate it says: Should I file this with my insurance on my own, I release [doctors office] from any financial adjustment to the prices listed above. So they've won this round. But I filed a complaint with my insurer before I received this, so hopefully they will give them some grief anyway.

This sounds very deceptive. First they tell you they don't deal with insurance and to file it yourself. Then this disclaimer lets them out if you do file... something doesn't add up.

Are they really in-network ? The fact they wouldn't file your claim is suspicious.

Contact your state insurance dept in addition to the insurance company

[soupcxan]

This office was recommended to me by more than one other person, and is listed as a "center of excellence" with my insurer for their speciality, so the shenanigans are kind of surprising.

[jollystomper]

Quote:

Originally Posted by soupcxan This office was recommended to me by more than one other person, and is listed as a "center of excellence" with my insurer for their speciality, so the shenanigans are kind of surprising.

Perhaps because no one has yet to report them on what they were doing... maybe folks just don't want to make the effort to "make waves", and feel that since they received good service they will just let it go. It would be interesting to ask those who recommended them if they had encountered this practice.

[sengsational]

Quote:

Originally Posted by SJ1_ If 1,2, and 3 do not work. Take them to small claims court. It would cost them a lot more than $142 to defend themselves.

You'll need to risk another $142 or so to sue them...small claims court ain't free. Not only that, you'd need to prepare your case. It is not worth it! Just trash them on every review site you can find and walk away.

[gauss]

The provider considers themselves either to be in-network or out-of-network with your insurance company on the day the service was rendered.

Either way, I would work it through your insurance company.

If provider considers themselves in-network, then the insurance company will be your leverage in getting the provider to honor the in-network rates.

If provider considers themselves to be out-of-network (ie they have terminated their relationship with the insurance company), then the insurance company should reimburse you subject to the terms of your policy with out-of-network services.

I find the facts as stated

1) Insurance company says provider is in-network
AND
2) Provider says "We don't deal with insurance companies, pay us now"

to be fundamentally incompatible.

Find out where the confusion is occurring and you should be able to resolve this.

I don't think this is a small claims case, but rather a case of misunderstanding.

If provider is not honoring the in-network rules, I suspect that the insurance company will reclassify them in their database as out-of-network and make you whole (according to your policy).


-gauss

[John Galt III]

Just one more datapoint for this thread: I went in for a blood test today at an in-network lab, and they wanted me to sign a release form. I started the form, but didn't sign it. They did the blood draw, then reminded me I needed to sign the form. I started asking questions about what it meant, and they cut me off and said "it basically means whatever the insurance company doesn't pay, you agree to pay". After accidentally knocking over a tray of empty vials, I politely told them that that wasn't how I thought it was supposed to work. They just sort of blankly stared at me and didn't say anything else. I quietly left without signing the form. I didn't have a chance to read the entire form but I think it must have been allowing them to "balance bill" me even though I am in network. Unbelievable.