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Out of Network Bill at an In Network Hospital
Old 04-22-2014, 08:57 PM   #1
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Out of Network Bill at an In Network Hospital

A family member had surgery last year. We went to an out of network doctor and are okay with paying his fee over and above what insurance will reimburse us for since we were aware of his charges upfront and contracted with him directly.

Our insurance has covered most everything else except one in hospital provider that was out of network at an in network hospital. It appears they did some kind of post surgery monitoring. Insurance covered some of their bill but they are looking for an extra ~$2K from us.

I have no idea what if this bill is reasonable or not for the services performed. I am not sure if it is worth turning over to a medical billing advocate for analysis or if that might cost us even more.

Would you just pay it? Negotiate to pay part of it? Hire an advocate? Or something else?

Any advice is appreciated.
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Old 04-22-2014, 11:04 PM   #2
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When I got hit with a bill that was unreasonable and not covered by insurance, I called to ask them why they were charging so much...


I got them to reduce the bill to the standard rate that would be paid by insurance... since I had not met my full deductible, I would have had to pay that amount anyhow...
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Old 04-23-2014, 06:42 AM   #3
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TP's approach sounds sensible. Did the hospital forewarn you about the out of network provider? I would be furious if I went to an in network hospital and got out of network charges. There oughta be a law...
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Old 04-23-2014, 07:12 AM   #4
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Several of these situations with my late mother. My practice was to go to the hospital and talk to someone in their billing office. Much easier to get things cleared up (and usually cheapened) when dealing face to face.
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Old 04-23-2014, 07:54 AM   #5
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.......... Much easier to get things cleared up (and usually cheapened) when dealing face to face.
Good point. It is kinda hard to grab them by the necktie over the phone.
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Old 04-23-2014, 08:39 AM   #6
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The hospital did not forewarn us. The doctors was out of network. Like Liam Neesan, he has a unique set of skills so he gets to charge what he wants and people pay it. We were okay with that because we wanted the best and not whoever was in network with but less expertise.

The hospital was in network. I am not sure what else a patient can do except not live in a country where you can go to an in network hospital, get charged whatever they feel like charging by an out of network provider you didn't know existed while you are unconscious and it seems to be perfectly legal.

Thanks for the advice so far. I will just ask them to accept the insurance amount as a first course of action and see what they say. The hospital's billing rate was 5 times what our insurance company paid, but because the hospital was in network they accepted it and wrote off the rest. The charges in question were not by the hospital itself but a third party provider.
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Old 04-23-2014, 08:49 AM   #7
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I would suggest you contact your insurance and tell them you did everything to stay In network. Usually it is the anesthesiologist that the In network surgeon brings in that is out of network. Challenge it with your insurance company and ask they pay this fee as In-net. Ask for an Administrative review if you do not get the result you want with the customer service rep..

Only after administrative review with the insurance company should yo go back to the hospital and ask for a discount on the fee.
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Old 04-23-2014, 08:55 AM   #8
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I would suggest you contact your insurance and tell them you did everything to stay In network. Usually it is the anesthesiologist that the In network surgeon brings in that is out of network. Challenge it with your insurance company and ask they pay this fee as In-net. Ask for an Administrative review if you do not get the result you want with the customer service rep..

Only after administrative review with the insurance company should yo go back to the hospital and ask for a discount on the fee.
I can ask for an administrative review, thanks for the suggestion. But FYI this bill isn't from the hospital. The hospital was in network and accepted what the insurance paid. This bill is from a third party provider that did some kind of post surgery monitoring and the bill is coming directly from them.
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Old 04-23-2014, 09:10 AM   #9
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I have a question because I want to learn from this experience. Did you not ask before hand if there would be any out-of-network work involved (besides your doctor)? I suppose even if you did ask that question, you would not necessarily get a correct answer. But just wondering if you did ask beforehand. I'm on your side - going to an in-network hospital, one would expect everything to be in-network.
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Old 04-23-2014, 09:13 AM   #10
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I think the main point you want to stress to your insurance company is...that you did everything you could to stay in network. The physician or hospital you hired (both in net) chose a third party vendor or provider which was out of your control. And they turned out to be out of network. It happens all the time, but it really depends on your insurance company, what their policies are on handling this.

Good luck...
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Old 04-23-2014, 09:33 AM   #11
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I have a question because I want to learn from this experience. Did you not ask before hand if there would be any out-of-network work involved (besides your doctor)? I suppose even if you did ask that question, you would not necessarily get a correct answer. But just wondering if you did ask beforehand. I'm on your side - going to an in-network hospital, one would expect everything to be in-network.
We did not ask ahead of time. We did not even know to do that since the hospital was in network. I am not sure we would have had much choice. I mean how many hospitals does a specific doctor have privileges to operate at and would you ever find one anyway where all the providers would be in network?

This hospital would only give out estimates after you already had your surgery scheduled, and to have your surgery scheduled you had to go through multiple surgeon pre-op visits and batteries of tests. The surgeon was out of town so by the time we got to the point of scheduling surgery we already had thousand of dollars in travel, our time and pre-op visits and test co-pays invested. It would not have been cost effective to cancel and pick a different surgeon and hospital combo in the rare hopes that all services outside of the surgeon would have been in network.
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Old 04-23-2014, 09:48 AM   #12
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We had a similar issue come up. DW had surgery, and anesthesiologist was out of network. She threw a fit and the anesthesiologist accepted the in network rate.
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Old 04-23-2014, 10:44 AM   #13
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The hospital was in network. I am not sure what else a patient can do except not live in a country where you can go to an in network hospital, get charged whatever they feel like charging by an out of network provider you didn't know existed while you are unconscious and it seems to be perfectly legal.
This is the situation in some Emergency Rooms in my area. The in-network hospitals staff the ER with out-of-network contract doctors. You're supposed to know this and refuse to be treated by a doc who is not in your network. Of course the trouble comes when you're unconscious at the time you arrive at the ER. A coworker who discovered this unhappy fact after her ER visit wants to design a medical-ID bracelet that says, "If you're not in X network, don't touch me!"
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Old 04-23-2014, 10:59 AM   #14
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A coworker who discovered this unhappy fact after her ER visit wants to design a medical-ID bracelet that says, "If you're not in X network, don't touch me!"
Rather than a bracelet which won't be noticed, maybe a 2' x 2' sign hung around her neck?
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Old 04-23-2014, 11:05 AM   #15
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Rather than a bracelet which won't be noticed, maybe a 2' x 2' sign hung around her neck?
Even better!
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Old 04-23-2014, 11:05 AM   #16
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Rather than a bracelet which won't be noticed, maybe a 2' x 2' sign hung around her neck?
Signs and bracelets can get lost or removed. Maybe a tattoo would be better.
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Old 04-23-2014, 11:15 AM   #17
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Signs and bracelets can get lost or removed. Maybe a tattoo would be better.
Might be hard to update the tattoo if your insurance provider changes. Also, the tattooed area might get crowded if you already have, like a guy I know, "DNR" tattooed across the chest.
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Old 04-23-2014, 02:36 PM   #18
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Signs and bracelets can get lost or removed. Maybe a tattoo would be better.
Used to wear a medical alert bracelet. Of the 25 times I'd seen Drs, been to ERs with it on, no one asked or looked at it. Perhaps if I'd been unconscious?
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