In-network provider refuses to accept negotiated rate

[soupcxan]

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

[ERhoosier]

Quote:

Originally Posted by soupcxan 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.


Sent from my iPhone using Early Retirement Forum

[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.

[John Galt III]

One more experience to report: I went in for routine annual physical and now they had the electronic tablet for me to update my contact info on, and, at the very last page, a waiver to sign. It stated, as usual, something vague about my being financially responsible for any charges not paid for by insurance. The front desk clerk politely gave me the phone number of their billing department for "any questions", when I asked for clarification. They let me in and did the physical even though I explained I could not in good faith sign the waiver. And it was on the darn e tablet so I couldn't cross anything out, or add anything. Maybe this is the wave of the future : don't sign anything and they perform the service anyway..................

[Jerry1]

The forms that ask you to sign and be responsible for the things that are not paid for by insurance are not the same as agreeing to be balance billed. Insurance companies have contracts that have clauses that prevent providers from balance billing. If they don't, get a new insurance company. The typical waiver is saying that if the service is deemed not covered by the insurance company, then the provider can bill you. These two things are consistent. If it's a payable service, no balance billing. If it's not payable, it's outside of the benefit of your insurance contract, and the provider expects you to pay.

If you are ever required to pay a provider, the first thing to do is ask for a discount. As in the OP situation, generally, the provider accepts $16 for something they charge $150 for. So start very low in the negotiation process.

Beyond that, these waivers are very weak as you are almost always signing the under duress. You're worried about your health/life and you're being asked to sign a form in order to get that service. Plus, you don't know if it's a covered service at the time you sign the form, I forget the legal term, but that is another out.

As described in this thread, I would work with my insurance company and my state regulatory agency. The unfortunate thing is that the trouble could easily be more that then money at risk here so it may be something to chalk up to a lesson and move on. However, if you have time, it's your money and it's likely you will prevail.

[soupcxan]

I got the appeal decision: denied! They said:

(1) They don't have a referral from my PCP for this, which is odd because they originally approved the in-network claim, why would they have done that if they didn't have the referral? And I sent them a signed copy of the lab order from my PCP. I don't know if a lab order is different than a referral but that's what I have.

(2) I signed the form at the doctor's office saying I would be responsible for the charges. From their letter it sounded like even if they had a referral, the doctor's waiver I signed gets both the doctor and Aetna out of paying me back.

So, not surprisingly, shitty service from Aetna.

[sheehs1]

soupcxan…This is the sort of stuff that makes me nervous going forward with my health care. It appears you did everything right and still were not supported by your insurer or the specialist.
Before year end and knowing my old policy would be better than the new one starting Jan1 I finally went to an orthopedist about the pain in my knee. I had banged it three times in a year. The most recent was a fall and weeks later the pain was still there. Ortho told me he thought it an arthritic flare, gave me a cortisone shot and slapped a knee brace on me. I was thankful for the shot as that cleared up the inflammation.
When I got my Explanation of benefits from Anthem I saw where they charged my insurer $2,000 for the brace. After what they paid, I still owed almost $600 for the brace since I had not met all of my deductible.
I gave it some thought ..let a week or so go by…and called the office of the Orthopedist telling them I should have been informed the brace was $2,000, that they should have TOLD me, that I did not need the brace never having used it and the more moderate approach would have been to see if the shot fixed things before slapping a $2,000 brace on me.
The office manager agreed and she wrote it off!! BTW..it could not cost more than $150 to make that brace.

[athena53]

Quote:

Originally Posted by soupcxan I got the appeal decision: denied! They said: (1) They don't have a referral from my PCP for this, which is odd because they originally approved the in-network claim, why would they have done that if they didn't have the referral? And I sent them a signed copy of the lab order from my PCP. I don't know if a lab order is different than a referral but that's what I have. (2) I signed the form at the doctor's office saying I would be responsible for the charges. From their letter it sounded like even if they had a referral, the doctor's waiver I signed gets both the doctor and Aetna out of paying me back. So, not surprisingly, shitty service from Aetna.

File a complaint with your state Insurance Commissioner. You may want to threaten Aetna with that first ("Thanks for your recent note; if this is your final decision then I will be filing a complaint with our state Insurance Commissioner since I believe these costs should be covered"). I can't guarantee what they'll decide but companies really hate to get reported to the State Insurance Commissioner.

[pb4uski]

+1 Call Aetna, tell them that the denial is unacceptable and tell them that you will file a complaint with the insurance commissioner in 3 days unless they get back to you with a different decision. Another angle would be to write a letter of complaint to the President or the CEO... when I worked at an insurer those letters got special handling by more experienced officers (unfortunately, for a short period of time... me )

Your PCP should be able to confirm that he referred you to a specialist... I would think that it would be in their records. IIRC, the form that you signed essentially said that you would be responsible for any charges that were not covered by your insurance so that doesn't get your insurer off the hook for their contractual responsibilities.

[Meadbh]

Threads like this remind me to be thankful that I live in a country with a universal health care system, despite all its flaws.

[travelover]

I can't comment on the merits of your case, but my experience is that as a retiree, I have the time (and devious desire) to grind companies down until they cry uncle.

I even got Social Security to refund all the money they grabbed from me via an IRS tax refund garnishment.

[meierlde]

Of course if you take traditional medicare the issue of network is simple either the provider takes medicare or they don't and if they don't they can't force you to pay more, all they can do is decline you as a patient.

[swakyaby]

I know this must be frustrating, time-consuming, and distracting, to say the least. Everyone here wants to hear you got the decision overturned, including a number of doctors who have chimed in. Although both your insurance Aetna and the so-called in-network provider rejected your claim, there are still avenues that can be pursued, if you think the principle of the matter is worth it. There are patient advocacy groups that can be consulted, and a complaint to the state insurance regulatory commissioner can be initiated. These all take time . . . just hate to see anyone get treated the way you have, and get away with it.