Something to watch out for

[Capwest28]

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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[John Galt III]

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.

 

[travelover]

....... 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.

 

[pb4uski]

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.

 

[jim584672]

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.

 

[travelover]

..........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?

 

[pb4uski]

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.

 

[MBSC]

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.

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

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

 

[athena53]

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.

 

[travelover]

.........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.

 

[pb4uski]

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.

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.

 

[John Galt III]

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.

 

[John Galt III]

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.

 

[Car-Guy]

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...

 

[mamadogmamacat]

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.

 

[Texas Proud]

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....

 

[John Galt III]

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.

 

[Car-Guy]

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.

 

[John Galt III]

.......... 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.

 

[EastWest Gal]

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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[eytonxav]

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.

 

[John Galt III]

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.

 

[pb4uski]

That's not totally surprising.... sort of like "we have to pass the bill so that you can find out what is in it".

 

[GTFan]

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

 

[lawman3966]

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.