Doctor's office set me up?

[RBisDebtFree]

Hi everyone,

I went to doctor A that was covered under my insurance and that doctor A sent me to another doctor B for some tests. Doctor B didn't renew the contract with my insurance company and was out of network for almost 11 months at the time of service. I asked the receiption and he told me and then confirmed (when I double-checked) that the doctor is in network. So I get a $1200 bill, nothing is paid by insurance, I call the billing department and after a long conversation we got the balance down to $538 and put it on a $50 payment plan. The "billing lady" said that we sent the contract renewal in back in september, we didn't know it will take so long for your insurance company to process it. After all, neither insurance nor the doctor's office is guilty and all the liability is on the patient (me).

Now I know that I should be checking with the insurance company myself. However, I still feel that I am being fooled and mistreated, maybe it's just my feelings.

My question is: can I do anything at this point? The director of the clinic said that max they could do is knock the bill down to $538. Could I take this to a small claims court? Would that even make sense? Should I talk to my insurance and ask them to process the claim as in network becase the doctor submitted contract renewal in Sept and I was getting service in Dec? Please advise!

Thanks in advance...

[nerves]

My recommendation would be to file an appeal with your insurance company. If you don't get resolution, send a letter to the insurance commission with the insurance company and the doctors organization cc. You may be surprised who quickly this will be resolved. The insurance company and the doctor's office does not want to be contacted by the Insurance Commission. I believe they have ten days to respond to your complaint. Best of luck to you. Keep us posted on the status/outcome.

[RBisDebtFree]

nerves, thank you so much for such a prompt response!

How would I file an appeal? Would it be something on the insurance company's web-site?

Also, if I have to file a complaint, should I be looking to do that through my state insurance commissioner's web-site?

Thank you!

[nerves]

If you go to your state's insurance commissioners website, there should be an address for you to send a complaint. You should try the appeal process with your insurance company first. If you don't get resolution in a timely manner, you will have additional information to state your case. All written correspondence you send for your appeal should have the doctor's office cc in. Then, neither party can claim they weren't aware of this or that. Lay all the cards on the table. If you don't receive a response with your first letter within 15 days, send a second and advise that you would like their cooperation to resolve. If you don't receive a response within 15 days of the second letter, advise the next action will be to have the insurance commission assist with mediation. If you end up going to the insurance commissioner, most states require a response from all parties within a specific time frame outlining the resolution, etc. What a pain in the ass it can be. There is so much fraud that takes place in the medical billing and settlement. Most likely neither party will want the insurance commissioner snooping in their books or billing/settlement practices.

[RBisDebtFree]

Thanks! That's a lot of good info. I have a couple more questions:
1) By CC doc's office, you mean just send a copy certified mail with return receipt requested to doc's office as well as to the insurance company?
2) Should I be making payments on my monthly payment plan? Or should I state that I request payments to be on hold for the time that the appeal (and possibly a compaint to the insurance commissioner's office) is in progress?

Thank you!

[nerves]

you will want to send a carbon copy to the doctor's office. I would recommend certified mail. Since you are giving them approximately 30 -45 days to resolve, it is a catch 22 on the payments. I think if you make one payment during that time, you should be okay as you most likely have a co-pay if they settle. I see this as part fault with the doctors office since they told you they were in the network. That is most likely what the insurance company will come back with. I would word the letter in something to the regards that the insurance company and the doctors office need to work this out together and your financial liability is limited to the co-pay amount - nothing less and nothing more.

[RBisDebtFree]

I agree. Thanks once for the information!

[Flamingo]

When Doctor A referred you to Doctor B, your responsibility was to find out via calling your insurance company directly or viewing the listing of covered providers for your insurance plan on their website (all this info was given to you when your insurance was renewed or obtained) whether or not Doctor B was a provider for your particular insurance coverage. It is not the responsibility of Doctor B's office to find out that information for you. They may take your insurance coverage but if the doctor is not listed as being a provider under your particular plan you will get stuck with the bill. Yes you can fight and appeal this but it may come down to what I just said above - it was your responsibility. Right on the back of your insurance card is a number to call to check on providers if there are any questions as to coverage and you can always search for a covered provider for your own insurance plan via the insurance company's website to avoid problems such as this. When you are referred to another doctor by a doctor covered under your insurance, always check with your insurance company first, via calling or on their website, that the new doctor is covered under your Plan to avoid having to pay because you listened to someone give you incorrect information.

[tigergem]

I had something "sort of" like that happen. Sort of. The doctor I went to was listed as "in network" in my plan booklet. But when I actually got to the doctor's office there was a HUGE BANNER on the wall stating "WE NO LONGER ACCEPT...(yeah my) INSURANCE". No kidding. I had driven 2 hours to get there. At the time I made the appointment, I made sure to ask, do you accept - - - and do you accept assignment? Oh yes yes no problem. Come on in. Then I meet THE BANNER. So the doctor agrees to see me anyway and NOT CHARGE ME for the visit. Very nice of him. But then I saw later that he submitted the claim anyway, and was paid... anyway. Whatever.

[RBisDebtFree]

Yeah... well, my insurance company said that if the doctor's office calls the Providers' Relationships department, then they might "talk the insurance company" to handle the claim even though the doctor was not in network at the time of service. However, the doctor submitted the renewal contract 4 months before the time of service.

We'll see...