In-network provider refuses to accept negotiated rate

[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]

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]

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

 

[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]

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]

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]

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]

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.

 

[soupcxan]

The complaint is pending with my insurer. We'll see how it goes.

 

[ERhoosier]

The complaint is pending with my insurer. We'll see how it goes.

PLEASE post a follow up.
It seems this issue is becoming more widespread lately.

 

[soupcxan]

But, I wouldn't be surprised if it takes them a month to get back to me.

 

[iac1003]

Usually when one signs that waiver form it means if it turns out that your insurance doesn't cover that particular service or procedure, then you are responsible for payment.

It DOES NOT mean they can balance bill you the difference between their rate and the negotiated rate.

This is unconscionable on the part of these medical practices.

So glad I am retiring from medicine soon.


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[rbmrtn]

This is illegal ( varies by state ) and should be reported to your state regulatory agency

Balance Billing—How To Handle It

State Restriction Against Providers Balance Billing Managed Care Enrollees | The Henry J. Kaiser Family Foundation

 

[Gatordoc50]

I remember having patients come in stating that I was on their list of providers when in fact I never joined any networks. But it sounds like in your case that the provider admitted to being in network but refused to abide by their fee schedule. Crazy. Sounds like they are using the network to troll for patients who aren't aware of their rights.

 

[John Galt III]

Getting off track just a bit, but what does one do when confronted with the waiver form before receiving service? In the past I have just verbally confirmed what it meant, and even though the wording was ambiguous, I signed it once the person confirmed it did not mean balance billing. I wonder if you could just refuse to sign it, along with speaking the the appropriate buzzwords, whatever they are, and still get service.

 

[swakyaby]

I applaud JohnGalt for not giving in to signing a form that allowed the in-network lab to charge more than the agreed upon in-network rate. When asked to sign such a form before services are rendered, I think I would cross out the sentence agreeing to pay whatever insurance does not cover, then sign.

As for the OP, I think it is unfortunately becoming more commonplace for such pay-upfront-the-entire-bill shenanigans, then being told to bill the insurance yourself to be reimbursed. That is an out-of-network provider hassle. I fell for that last year too. And I felt cheated and deceived, but I let it go. I think if you wanted to take action, I would make a formal complaint to the state insurance regulatory agency. I think complaints to the state medical board are only entertained for allegations of medical negligence or fraud, but I may be wrong. And I would definitely tell the PCP office that they made an improper referral to a specialist who definitely did not practice in-network billing. It makes me angry when insured patients are jerked around like this.

Now, when I make an appointment with a new doctor or laboratory, I verify with their office whether they are in-network with my insurance plan. Then I verify with my insurance what my copay is, if anything, and stick to it if the front desk employee insists I pay more. I would be prepared to call the insurance company right then and there, and have the insurance company "explain" to the provider's office manager what being in-network means.

 

[robertf57]

Before you do anything else, please file a complaint with the State Board of Medical Examiners. This is improper in Texas. Better yet, inform them you will be filling a complaint if your refund isn't received in 72 hours. This just chaps me ....

 

[Htown Harry]

Good luck, OP.