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Old 12-11-2015, 04:00 PM   #21
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At my PCP annual physical I have refused to sign the waiver, and they took me in anyway. As far as PPO being any better than HMO for out-of-network, seems like being billed 20% of some huge number is almost as bad as bad as being billed 100% of some huge number. i.e., I would refuse to pay either one. Maybe we're getting to the point of just refusing to pay, and living with whatever consequences come from that, since doing everything one can to prevent out-of-network providers does not always work. At my recent visit to the eye doctor, they gave me a plastic form to sign with an erasable felt tip pen. I wrote "copay only" next to the financial part, and asked for a xerox copy They acted like I was the only one to ever ask for a copy, but they did give me a copy.
Another thing to watch out for is the "electronic document scam".

Days before my colonoscopy, they gave me all of the stuff to sign. I made a few adjustments like the saying I only agree to pay in-network rates. When I got there, they had me sit down and re-sign the electronic versions of the documents with a stylus. I caved-in and did it, so my paper documents were trash.

One other thing happened that time....I did call the anesthesia company before the procedure and asked about the price of the propofol (not covered) vs waking sedation (covered). I got a price of $100 over the phone. Of course they billed more, $300. I called and said they'd not see a dime unless they agreed to accept $100 as payment in full. I had them send me a new bill for $100 before I paid. Slimeballs.
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Old 12-11-2015, 05:24 PM   #22
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Same here - except the regular (vs medicare) version. I make sure to go to a Kaiser facility and am assured the practitioners - all of them - are in network. Emergency room visits to a non-Kaiser facility are covered as well. Basically everyone is out of network at a non-Kaiser facility - but they cover at their HMO rates. And in CA they can't balance bill. Since I'm satisfied with the Kaiser Docs/NPs/PAs... it's a winner for me.
+1. It's also really convenient that all the specialists I get referred to already have access to my medical records. Plus, they're also the cheapest option through work ($0 employee share in premium). The other choices, I'd have to pay part of the premium.
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Old 12-11-2015, 05:47 PM   #23
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Non-Medicare Advantage Kaiser is not cheap BUT they are fantastic when dealing with kids who always seem to get sick after the clinic is closed.

FWIW Kaiser has offered to assume (buy?) Group Health in Seattle Metro. When Group Health was in financial trouble ~15 years ago Kaiser stepped as administrator and brought them back to health. Group Health & Kaiser coordinate benefits and care for their respective members. Kaiser members who get sick in Seattle are cared for by Group Health, Group Health members can go to Kaiser facilities wherever.
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Old 12-11-2015, 06:38 PM   #24
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I just ran into this situation last week. I went in for a colonoscopy. They had a piece of paper listing the anesthesia group they use. I asked the nurse about them. I said I know that the GI doctors are in network but don"t know anything about the anesthesia group. She said not to worry. That they will work with my insurance about payment. Right. Had no choice at that point. Will see what happens with the insurance.
In my case the facility provided the anesthesiology - a nurse I think. The facility was in network, so no probs.
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Old 12-11-2015, 06:50 PM   #25
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What You Can Do Now

Here's what we can do about this problem today:

https://consumersunion.org/surprise-medical-bills/
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Old 12-11-2015, 07:00 PM   #26
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I had the same experience as mn54. No bill from anesthesia yet, but they were paid as out of network. I verified with two people that the group was in network. We shall see.


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Old 12-16-2015, 02:41 PM   #27
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Originally Posted by sengsational View Post
Another thing to watch out for is the "electronic document scam".

Days before my colonoscopy, they gave me all of the stuff to sign. I made a few adjustments like the saying I only agree to pay in-network rates. When I got there, they had me sit down and re-sign the electronic versions of the documents with a stylus. I caved-in and did it, so my paper documents were trash.

One other thing happened that time....I did call the anesthesia company before the procedure and asked about the price of the propofol (not covered) vs waking sedation (covered). I got a price of $100 over the phone. Of course they billed more, $300. I called and said they'd not see a dime unless they agreed to accept $100 as payment in full. I had them send me a new bill for $100 before I paid. Slimeballs.
I went to see a specialist today. The front desk clerk wanted me to use the digital pen to sign an electronic pad on the counter, indicating my "consent". I asked to see what I was consenting to. She whipped out a plastic form with the usual junk, including the financial responsibility. She said it was all or nothing : sign it or we won't see you at all. I decided to sign it, since I had spent a lot of time researching urologists and didn't want to miss the appointment.
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Old 12-16-2015, 03:25 PM   #28
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....... sign it or we won't see you at all. I decided to sign it, since I had spent a lot of time researching urologists and didn't want to miss the appointment.
They have a way of bending you over twice.
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Old 12-16-2015, 05:14 PM   #29
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This whole surprise out-of-network billing issue is slowly becoming the Achilles heel of health care in the US. We need legislation that if you are admitted to an in-network facility then all providers who work on you while you are there will accept your insurers negotiated rate for in-network providers. Also, that emergency services will be covered in-network and that no out-of-network billing can be made unless the patient specifically approves the out-of-network service provider in-writing and that if the patient refuses to do so that the facility is required to provide an in-network provider.

The current system, which seems to expect patients to control whether their providers are in-network or out-of-network, is ludicrous.
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Old 12-16-2015, 05:29 PM   #30
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In my state, New York, they passed a law to prevent these out of network surprise bills. If it happens you fill out a form and only pay your in network payment only.
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Old 12-16-2015, 05:30 PM   #31
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..........We need legislation that if you are admitted to an in-network facility then all providers who work on you while you are there will accept your insurers negotiated rate for in-network providers. Also, that emergency services will be covered in-network and that no out-of-network billing can be made unless the patient specifically approves the out-of-network service provider in-writing and that if the patient refuses to do so that the facility is required to provide an in-network provider...........
Ah, you do know that most legislation is written by lobbyists? And the lobby that would support your very logical proposal is either non-existent or severely underfunded?
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Old 12-16-2015, 05:55 PM   #32
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Sounds like NY legislators figured out a way to do it. Actually, that gave me an idea.. I know one of our state legislators quite well... perhaps I'll do some research on what NY has done and talk with her about it.
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Old 12-16-2015, 06:26 PM   #33
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We need legislation that if you are admitted to an in-network facility then all providers who work on you while you are there will accept your insurers negotiated rate for in-network providers.
2017 CMS Proposed Rule for Marketplace plans.

Quote:
CMS Proposed Annual Notice of Benefit and Payment Parameters for 2017:

In an effort to reduce surprises consumers may face after buying a policy, CMS is seeking comment on a requirement that health plans in the federal Marketplace count certain out-of-pocket expenses on unexpected out-of-network services towards a policy holder’s annual out-of-pocket maximum, if the service was performed at an in-network facility and advance notice was not provided.

For instance, if a patient who had surgery at an in-network facility finds out later that their anesthesiologist was not part of the health plan’s network, cost-sharing charges for that anesthesiologist’s services would count toward the out-of-pocket maximum, protecting the patient against additional financial liability. Currently, these types of out-of-network cost-sharing charges are generally not counted towards the out-of-pocket maximum.
Reference: CMS Proposes improvements for the 2017 marketplace

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Treating certain out-of-network expenses as in-network – Insurers offering plans in any Marketplace would have to provide individuals at least 10 days’ notice prior to a procedure at an in-network facility if the individual might receive out-of-network services, for example from an out-of-network anesthesiologist. If the notice is not provided, the individual would be allowed to count the out-of-network cost sharing against his or her in-network out-of-pocket maximum.
Reference: Pre-Thanksgiving ACA Regulation Dump €“ 2017 Proposed Benefit Payment Metrics - Crawford Advisors
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Old 12-16-2015, 06:37 PM   #34
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I sure hope those laws pass- but CMS is the Center for Medicare and Medicaid Services. The rest of us would like this, too!


Here's a sad case from NJ. Wife rushed to hospital for emergency C-section and the hospital, which was in their network, outsources its anaesthesiology to a group that was out of their network. This is a highly-regarded hospital; Michael Douglas and Catherine Zeta-Jones went there for the birth of their last child.


Judge rules Franklin Lakes parents must pay surprise out-of-network medical bill - News - NorthJersey.com


There are still a lot of problems to fix with our healthcare system.
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Old 12-16-2015, 06:43 PM   #35
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.........the hospital, which was in their network, outsources its anesthesiology to a group that was out of their network..........
Not all pirates are off the coast of Somalia.
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Old 12-16-2015, 07:17 PM   #36
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That judge may well be right on the law but it is just plain wrong that the patient should be required to pay anything beyond what they would pay an in-network provider in such situations. Changes need to be made.

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The form explains that some doctors involved in patient care at the hospital are not hospital employees and may not accept the same insurance plans the hospital does. It notes that the patient will receive separate bills from the hospital and other professionals and is responsible for both.

Anthony Cristiano wrote “Do Not Agree” across that section of the form.

That didn’t matter, the judge’s decision said, because the form is not a contract.

The patient “may believe that she informed the Valley Hospital that she did not agree to accept services” from doctors who are not in her insurance plan, Bachman wrote, but that “does not mean that [she] can dictate which medical group may provide services to her while at The Valley Hospital.”
This judge is an idiot... a patient can't dictate which medical group may provide services to her? Also, the form her husband wrote "Do Not Agree" across isn't a contract but the anesthesiologist didn't have a contract with the patient either.
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Old 12-16-2015, 08:13 PM   #37
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This whole surprise out-of-network billing issue is slowly becoming the Achilles heel of health care in the US.....
Maybe I missed it but I can't remember hearing any talk about this problem from political candidates, at least not in the debates, so far. I'm convinced the out-of-network events are pre-planned since they make so much money for the providers/hospitals.
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Old 12-17-2015, 04:33 AM   #38
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One more thing to watch out for. I just saw the explanation of benefits for my recent visit to the optometrist. I'm OK with it because I have very low copays. For someone with high copays, like $50, it wouldn't be so great. In this single visit to the optometrist, they managed to charge me 2 different copays. $5 copay for the office visit. And a $10 copay for an *outpatient procedure*, which was photographing of the retina. I was in the same building during the entire visit, but did get moved into a different room for the retinal photo. Of course no one mentioned getting stung with an additional copay during all my calls to the ins co and to the optometrist prior to the visit. And the amount of the *office visit* copay was never certain before the visit, and even during the visit. The clerk tried to charge me a $20 copay. My ins card said $10. And the customer service people at the ins co told me various numbers : one said it would be free, one said $5 (you win!) and one said $10. Again, the damage to me is minimal, since I am lucky to have low copays, but the whole med ins scenario is still the Wild West, apparently.
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Old 12-17-2015, 08:10 PM   #39
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I'd laugh if it wasn't so sad and true.

Earlier this year, a family members primary care physician order some test from the local lab. Both the DR and lab are co-located and were "in our network" at that time. We've been using them for years without any issues. A few months later, the doctor ordered the test again. Unknown to us, the lab we had been using for years had changed ownership and are no longer part of our network. Same office, same lab, even the same personnel, and no one said anything, even after accepting our insurance card.

The tests that were done earlier in the year was paid for by our insurance and cost us nothing (zero). This time, the insurance paid a portion for the new test (out of network rates) but now the lab is billing us for the rest. It's not a lot of money. If we had been informed (or signed something ) I might feel obligated to pay. As it is, I think I'm not going to pay (or ever go back to that lab).

We plan to talk to the doctor about this and request an in network lab in the future or we're going to find a new doctor (and lab).

I have had several similar (in network/out of network) incidents in the past couple of years. Never had any issues before...
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Old 12-17-2015, 09:42 PM   #40
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Had a similar emergency room experience in 2011. The hospital was in network. I had no choice of which dr who treated me. He was quite good, but later turned out to be out of network. A bill I expected to be $20 was now $200. Called the ins co (aetna), after callnig the dr's office to complain, and they got the dr's offcie on the line again after I insisted on the unfairness since there was no choice who treated me, ultimately, I only paid the $20. No emergency room visits since, fortunately. But, what a hassle. Will be sticking with my mega corp retiree medical during my first yr of ER just to keep the aetna network, which is quite large, and not have to deal with changing any of my doctors. As costs rise (so far within budget but still a lot) may move to Kaiser, just to avoid issues such as this. Unfortunately, Aetna does not particpate in the exchanges in my state.
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