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Old 12-17-2015, 11:43 PM   #41
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Heck, it is almost impossible for the docs etc. to keep up...

We went to an eye doc and was going to pay out of pocket... just a regular visit... but the doc 'saw something' and had us check for insurance... they said they were in our plan.... but we needed a referral from our PCP... SO, we go to PCP (who we had never seen before) and she looks and low an behold... eye doc NOT in our network...


Now our PCP has moved on and is no longer in our network... so I am looking for another... the third in just a bit over 1 year....
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Old 12-20-2015, 08:45 AM   #42
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Not to drag this thread on forever, but... I just remembered a post from another forum member stating that these consent forms we are forced to sign are not enforceable and/or perhaps not even legal. I hope he is right. The same way a prenup that you sign turns out to be unenforceable (denied by a judge) when you try to use it! One can hope.
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Old 12-20-2015, 01:06 PM   #43
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Supporting the OP in related experiences. As recently as last year, our insurance company would send us a form letter anytime a medical service provider (DR, Lab, facility, etc) "that we had used in the past" dropped out of their network. That does not happen anymore.

Relating to my earlier post on this topic, I'm finding that more and more often, that while our doctor may be in-network, the lab that they use or the facility where they practice is not. This is especially true for doctors that practice at multiple locations. We have one doctor that we see at different locations from time to time. The doctors office visit is always covered as in-network. However, other associated services, procedures or test that he may order, may or may not be covered depending on which location we see him at.

If you haven't experienced this "crap" then you've been lucky. IMO, it's getting worse, quickly.
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Old 12-21-2015, 07:47 AM   #44
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.......... Relating to my earlier post on this topic, I'm finding that more and more often, that while our doctor may be in-network, the lab that they use or the facility where they practice is not. This is especially true for doctors that practice at multiple locations.
I'm having this experience now. I'm checking out who is in network for an HMO I am enrolling in. I found Dr. Smith was in network, but the address at which Dr. Smith practices is at a hospital NOT in network. I called up customer service at he ins co to ask about it and they were clueless. On a related note, I found Dr. Jones was in network, and also his office location (non hospital) was also in network, according to the website. Just to be sure, I called Dr. Jones's office and the clerks there refused to confirm that he was in network!! They said they don't trust the insurance companies, and did not want to get sued by patients for giving out false information.
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Old 12-21-2015, 08:03 AM   #45
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Ask to speak to the office manager. A doctor isn't going to get sued for his/her staff answering such a question incorrectly. It's not malpractice, for goodness sake. The front office staff don't always know the answers to such questions.

You have a right to know if your doctor and facility are in network. Don't let them get away with it.


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Old 12-22-2015, 09:55 AM   #46
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And then to add to all of this, so many in-network providers are being shrunken down by the insurance companies and do not cover many of the better quality providers as in years past. We are doomed.
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Old 12-24-2015, 07:36 AM   #47
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I just have to add this. I went in for an ultrasound yesterday and the clerk asked me to sign the electronic pad after she asked my name and my insurance. I asked to see what I was signing for, and she said "We only show you that after you sign the pad" with a deadpan expression. It's getting to the point of just being funny, like something out of a *Far Side* cartoon.
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Old 12-24-2015, 07:48 AM   #48
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That's not totally surprising.... sort of like "we have to pass the bill so that you can find out what is in it".
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Old 12-24-2015, 11:11 AM   #49
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I had a nice little surprise with my short emergency and observation room stay in a network hospital. Most bills were paid in network benefits. But a couple Doctor who visited me or looked over charts billed and were not paid, They were out of network! in the in network ER. Okay I looked into this and am filing an appeal because Emergency is supposed to be covered even for out of network Doctors.

But if you go have surgery or any other procedure, if a out of network is used in your in network facility. Tough Luck to you. You are responsible. I have had hmo for years and being not having run into this before mostly because luckily have not had health issues.

This is ridiculous and basically out of your control, it will be hard to make sure everyone only in network is used when you are not the one sending to labs or a dr looks at your charts and on and on. Just giving this for others to beware!
The Emergency provisions in the ACA say that the plan must pay emergency costs as if they were in-network, so you should be ok on the docs. However, that does not prevent them (in most states) from balance billing you on whatever they feel like if the in-network payment is not sufficient to them.

For the surgery issue, we just ran into that - my wife broke her leg while we were vacationing in DC. Fortunately we got sent to an in-network hospital but the surgeon that fixed her leg was OON. As was the anaethesiologist. Humana paid the hospital and all the docs except for the surgeon, so we appealed and just found out that they are now paying him too.

The whole in/out of network system is broken for all the reasons mentioned here, but from what I've read the usual suspects claim it's too difficult to fix.

Some states have taken action:
The Hospital Is In Network, But Not The Doctor: N.Y. Tries New Balance Billing Law | Kaiser Health News
Out-of-network costs lurk even at in-network hospitals - LA Times
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Old 12-24-2015, 05:58 PM   #50
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I have thought about carrying such a piece of paper on my person, something like, "I only consent to be treated and billed by in-network physicians. I will not be responsible for any out-of-network charges without my express consent."

But with electronic health records where would they store it, how would they communicate it to said physicians and would I be lucid enough to whip out the paper to show them?


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I've heard of retirees in the Philippines attaching "dog tag" like bands to their wrists to prove they have insurance so that, in case they need treatment and are unconscious, the hospital will admit and treat them. Otherwise, the hospitals there can leave you on the street.
A similar approach could be tried in the U.S. for the purposes of stating what treatments will be paid for.

I've heard many stories of out-of-network doctors providing unneeded services. I have come to believe that it is done on purpose in order to generate fees that are not subject to insurance company reimbursement schedules, and which can thus be more lucrative.
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Old 12-24-2015, 10:14 PM   #51
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All of our local hospitals are "in network" for Blue Cross, United Healthcare and the big national insurance companies.

My gripe is with the emergency room physicians--none of which accept "in network" payments. Heck, they don't even work for the hospital. They're working for whatever they can squeeze out of insurance companies and individuals' pocketbooks. Don't pay'em and watch your FICO score drop as they'll report you as a chargeoff.

When I go into the emergency room, I've seen the same bunch of people (as 5 years ago) using it as an unpaid clinic. They're the subculture group of people that don't know enough to even sign up for O'Bamacare. They wouldn't pay co-payments or deductibles--even if they could afford it.

But I'm still thankful that my wife and I have Medicare with a fine supplement purchased at reasonable prices through my ex-employer, MegaCompany.
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Old 12-25-2015, 09:06 AM   #52
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.... I've heard many stories of out-of-network doctors providing unneeded services. I have come to believe that it is done on purpose in order to generate fees that are not subject to insurance company reimbursement schedules, and which can thus be more lucrative.
Yes, this is the screaming elephant in the hospital that people don't seem to see or hear. As the old cliche says, follow the money.
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