In-network provider refuses to accept negotiated rate

[soupcxan]

My primary care physician ordered a test on me and gave me a referral. I went to another doctor's office (a specialist) to have the test done. The specialist is in-network with my HMO. My HMO covers this test if I have a referral from my PCP. The specialist's office tells me: we don't deal with insurance companies, so you'll have to pay cash up front, but you can submit the bill to your insurer afterwards. I say ok and pay $150 upfront for the test. I sent the receipt, the referral, and a claim form to my insurer.

Three months later, my HMO processes the claim. They advise that the specialist was in-network, and the negotiated rate for this test is $8.00, and that my co-pay is $8.00. I call the specialist to ask for my $142 back and they say that the fact that they are in-network and they have a negotiated rate is irrelevant. They refuse to return any money. I call my HMO and we call the specialist on a conference call and the specialist says I signed a waiver of the right to get negotiated pricing (I'm sure I signed something at their office but it was months ago so I'm not sure what it said). They say they will send me a copy of this waiver. So far, I have received nothing. They said that if my HMO wants to reimburse me $8.00, that's between me and my HMO.

Now, I can live just fine without this $142. But the principle of this bothers me, as does the specialist's reaction. I went to them specifically because they were in network and because they told me I could submit the claim myself. What would you do?

1. File appeal with insurance company and see if they pursue a contracted provider for not honoring their contracted pricing.
2. File dispute with my credit card company reason "I was charged the wrong amount" and send them a copy of my HMO's negotiated pricing
3. File dispute with the Texas Medical Board as this specialist is practicing "balance billing" which is prohibited by law.
4. Leave negative reviews on Yelp, BBB, etc.
5. Something else?

 

[Disappointed]

I would do all 1-4.



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[MRG]

I had a slightly similar situation and successfully made option #1 work.

I would also file your complaint with your states insurance board.

You said texas i guess it's your country's board.

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[ERhoosier]

Perhaps all of the above.
Sounds as if that specialist is now refusing to honor their in network agreement. Not even sure if a patient can waive an insurance company's negotiated pricing for a specifically covered (and PCP ordered) service. Wouldn't that defeat the main purpose of a provider network agreement from the patient and insurance co viewpoint?

 

[daylatedollarshort]

I researched the same issue once. Our insurance has a complaint process for in network doctors that balance bill. If the doctors don't want to accept the insurance companies rates or deal with them in any way, they shouldn't really get to stay on the in network list.

I didn't follow up with my complaint as it was a service provider with particular expertise we needed to see again, but otherwise I would at minimum have started with the insurance company complaint.

 

[perrytime]

why not get local TV news help reporter coverage to throw neg publicity on this scammer.

 

[Lakewood90712]

I have a different view.

How in the world would anyone expect a medical provider to see the patient ( even if not by the physician) , perform a test , and do this for $16 total . Just the office overhead is more than that. I don't know who is more absurd, the Dr. for agreeing to be in network with this insurance co , or the insurer for the reimbursement rate. You can't even get a good oil change on a car for that cost.

I have a high priced, high benefit PPO ,. My co-pay is $30. Dr. bills $140 for a limited visit . The Dr. accepts $90 , including the co-pay. I consider the $30 co pay the cost of overhead just to maintain the office staff and billing costs.

 

[soupcxan]

I have a different view.

How in the world would anyone expect a medical provider to see the patient ( even if not by the physician) , perform a test , and do this for $16 total.

There was no office visit. This was just a (relatively common) lab test at the specialist's office. I don't know whether the doctor himself even looked at the results as this is not a test that requires a lot of interpretation/judgment in the results. I never saw the doctor nor spoke to him directly.

And regardless, if $8 is not enough to cover the cost of the test, why did the doctor's office agree to it as the negotiated pricing with my HMO? If $8 is not enough, no one forced them to be in-network. An $8 loss leader may be the doctor's problem but I definitely don't see how it's my problem.

 

[Lakewood90712]

I wonder if several tests were ordered at the same time if they would still pull the " waiver ' thing , or just accept the agreed fees when bundled together . Like the way most doctors and hospitals do with medicare, order stuff not really needed to fluff up the gross $.

 

[clifp]

I like 1-4 also. Finally look at filing a small claims case. You probably can't against the insurance company, cause I am sure you agreed to binding arbitration, but maybe against the Dr.

 

[EastWest Gal]

There was no office visit. This was just a (relatively common) lab test at the specialist's office. I don't know whether the doctor himself even looked at the results as this is not a test that requires a lot of interpretation/judgment in the results. I never saw the doctor nor spoke to him directly.

And regardless, if $8 is not enough to cover the cost of the test, why did the doctor's office agree to it as the negotiated pricing with my HMO? If $8 is not enough, no one forced them to be in-network. An $8 loss leader may be the doctor's problem but I definitely don't see how it's my problem.

Why would you go to a specialists office for a lab test? If your PCP sent you there specifically, that indeed sounds strange. My alarm bells are going off--I'm thinking kickbacks etc. I would file an appeal with the insurance and go to your state insurance commissioner. Something about this doesn't smell right.


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[marko]

I have a different view.

How in the world would anyone expect a medical provider to see the patient ( even if not by the physician) , perform a test , and do this for $16 total . Just the office overhead is more than that.

If they don't take insurance, their overhead would be very low. My Dr just moved to a "Direct Primary Care" model where they don't take insurance. His overhead dropped so dramatically that he doesn't have to bill $300 for an office visit. He charges $4 for a blood test when he used to have to charge $174.

I pay him $80 a month and have full access to him, 10 visits a year, etc. included.

 

[Fermion]

He charges $4 for a blood test when he used to have to charge $174.

$4? Includes the disposable syringe, mailing costs, lab work, and time to make the draw?

Does he work out of a booth at McDonalds

 

[marko]

$4? Includes the disposable syringe, mailing costs, lab work, and time to make the draw?

Does he work out of a booth at McDonalds

I think you missed the point.

 

[MichaelB]

1. File appeal with insurance company and see if they pursue a contracted provider for not honoring their contracted pricing.
2. File dispute with my credit card company reason "I was charged the wrong amount" and send them a copy of my HMO's negotiated pricing
3. File dispute with the Texas Medical Board as this specialist is practicing "balance billing" which is prohibited by law.
4. Leave negative reviews on Yelp, BBB, etc.
5. Something else?

I would do 1-3, and also file a complaint with the State Attorney General. Item 4 I would consider once the case is closed.

 

[DayDreaming]

I would also tell this story to your PCP and suggest they stop referring patients to this specialist.

 

[utrecht]

This is exactly why I refuse to pay anything upfront at a doctor's office. They always charge the full amount and there is always a refund to the negotiated rate. Its always a pain to get the refund back. The doctor is the one who negotiated a contract with the insurance company to except the lower rate. They should be the ones worrying about collecting the extra money from the insurance company. Not me worrying about collecting my refund from them. In most cases I wouldn't have gone to them in the first place if it wasn't for their relationship with the insurance company.

 

[pb4uski]

I would go to or call the specialists office and talk to the doctor or the financial manager. Tell them that if they do not refund the $142 that you will pursue 1-4 and that the time and energy that they will spend defending themselves will surely cost them more than $142. If you are retired, tell them that you are retired and have loads of time to devote to causing them a stink. Give then 3 days to respond.

Be civil, but assertive and firm. The squeaky wheel gets the grease.

And if they refund the $142, after the check has cleared, do number 4 anyway and let your PCP know so they no longer refer patients to this specialist scoundrel.

 

[Mulligan]

This is exactly why I refuse to pay anything upfront at a doctor's office. They always charge the full amount and there is always a refund to the negotiated rate. Its always a pain to get the refund back. The doctor is the one who negotiated a contract with the insurance company to except the lower rate. They should be the ones worrying about collecting the extra money from the insurance company. Not me worrying about collecting my refund from them. In most cases I wouldn't have gone to them in the first place if it wasn't for their relationship with the insurance company.

This thread reinforces my dred in dealing with healthcare expenses as I age with a big deductible policy. Healthcare should be about healthcare, not penalizing dumb people (like me), gotcha fine print, and general billing confusion processes. I sure hope all my maladies hit me after I am on Medicare.


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[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.


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[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]

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.


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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_]

I would do all 1-4.
5. Something else?


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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]

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.


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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]

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