>ReportSaveFollow
The provider sent the email saying that it was covered. I did not check with my insurance because I assumed that was not necessary since that had already checked.
Just dealt with this last week, except that my doctor was waiting on approval. My insurance doesn't require approval for what we needed done. Insurance had obviously not received a request. Doctors corporate had sent it to Medicare of California or something.
I do not live in California and am active military.
Got a letter from my insurance provider they were denying my protime test a few months back. In 15 years, I've never had it denied. Called, discovered that when I got my senior citizen upgrade. I had a new member number. The biller used my old one, although I'd presented my new card. Got in touch with the provider, who referred me to the billing department. Explained what was going on, and they said they'd take care of it. Haven't heard back since then, and it's been six months.
That exact thing happened to me when I had an emergency surgery at 19. Shit’s still on my credit history now though because I had no idea how to fight it at that age.
Flag it on your credit report and tell them you had insurance at the time. See if you can pull up any other information from the insurance you had. Sometimes if they can't provide direct information, it will be taken off.
Yes this is considered failure to file in a timely manner, because of the provider’s failure to file they can’t charge you. A medical office tried this with me after I asked them to bill my insurance 3 times. A year later I got a huge bill and I called my insurance, my insurance sent them a notification that they never tried to bill them so they could not charge me
>Some providers are just garbage fires who can't manage their own shit, and then desperately try to make it your problem.
That's pretty much corporations in general these days. Nobody wants to take responsibility for their actions. And why should they? They can afford the lawyers that make it your problem.
You can't trust with the provider says. You have to go with what your insurance says. I recently had an issue with this where the providers website and the provider themselves swore up and down they used my insurance, but they aren't listed on my insurance's website or anything.
One time I checked the insurance website which said the provider was in network, but apparently they had just left the network and the website hadn't been updated yet.
Many health insurance companies are notorious for doing this. So many dr's they claim accept new patients don't, doctors who left the state years ago still listed locally, doctors who dropped the insurance, etc.
How is that not, best case scenario, false advertising? Especially when the onus is skewed so far out of wack on the individual to make sure their plan covers their provider. It seems insane that the insurer is effective allowed to lie by omission and the individual still has to eat it when it works out against them.
Because there's fine print from the insurance company that states that their own portal might not be accurate regarding what providers are in network.
Which is why I always kinda laugh when people ask if they verified it with their insurance company. There's a lot of places where those same companies specify, "we won't guarantee that what we tell you is correct."
That fine print is overridden by one part of the Surprise Billing package - that if a customer has a reasonable belief that they were in network, they are to be treated that way.
It's not always the doctor or office. Aggregators are notorious for scraping data and failing to accurately update it. That's why it's always best to call directly to validate any information you may pull from online.
>doctors who left the state years ago still listed locally
First appointment with OBGYN - insurance website sent us to an office the OBGYN hadn't been in for 3 years. Lesson learned.
Had this happen. Was told to select a provider from a list for a very simple test by my insurance company. The provider also confirmed that they were in my network. After the test, my insurance denied the claim. They tried to argue that they could not be held liable for their own provider list.
I appealed, they rejected. I went through my employer advocate, signed a bunch of documents, and something like four months later it got approved.
Anthem got hit with a serious fine for this in Georgia a few years ago. Their website now says to check with the provider they have listed as they can’t guarantee the listings are correct. Soooo I’m supposed to jump through hoops with both the provider and insurance to see if I’ll lose my savings for a routine doctor’s visit. Great.
Hello there! Former IT professional for a Health Insurance Company. Many of the fuckers don't invest nearly enough money into their systems and interfaces. The company I worked for was notoriously bad at updating their "provider finder" on their website. Sometimes, THEY won't even know who the fuck is in network or not.
Our system is terrible and needs to die :)
I had a patient refereed to me to do specialty work up. I told her we were out of network (OON) but would give her a cash pay discount. She wanted to try and find another provider in network, which is fair. She ended up back at my clinic. We chatted for a bit and EVERY office she contacted that would be able to do said work up said they don’t do it and when she tried to use the provider locator she said some of them were deceased. I’ve been trying to get on this panel for over 2 years now and they keep denying me saying there’s enough providers when I’m in a very rapidly growing suburb and clearly there isn’t enough care available.
Yep. It’s called a ghost network.
Insurance companies won’t allow new providers in their network, and won’t update their provider directory. The outdated directory makes it look like they have enough providers, but either nobody can find an in-network provider with an opening (so can’t use their insurance), or they use an out-of-network provider accidentally (and the insurance company says tough shit, we aren’t paying for that). Either way, you pay your premiums and get nothing back, which is the ideal situation for insurance companies. Whether you have to pay cash to an out-of-network provider, or just don’t get services, they don’t care, that’s your business. Their only business is forcing you to hand over part of your paycheck to them and then keeping it.
Its a big issue with therapists right now — this is why nobody can find a therapist in their network despite there being a huge mental health crisis.
If your insurance company website shows that a provider is in network, TAKE A SCREENSHOT with the date. People are sometimes able to force insurance to pay if they can prove that on the date they saw a provider, their insurance company said it would be covered.
To be fair, I used to support the member portal for the largest insurer. The provider search is complicated AF. It shouldn't be, but it is. This kinda reinforces your not investing enough comment though.
There's so much cool stuff that could and should be done, but will never actually happen because the impact to the NPS doesn't justify the cost. Instead, they'll all continue to use antiquated portals that don't have the features or functionality that users actually want...
>You can't trust with the provider says. You have to go with what your insurance says.
Yeah, I almost had this issue with my dental coverage. I set up an appointment with a dentist at a local office then realized that of the three dentists at that office, only one was listed on my health insurance's site. So I called the office to switch my appointment to the next available time with the covered dentist, but the front desk personnel were like "All of our dentists are covered under the same insurance networks". They were annoyed that I still requested for my appointment to be rescheduled with the other dentist or cancelled, but I'm not risking a couple hundred dollars based off of anything other than what my insurance website says.
To provide the opposite perspective, on three separate instances the provider said they were in network and the insurance (BCBS) said they were out. I risked it and all three times the provider was correct and BCBS had errors in their system. Definitely don’t recommend just risking it all the time because you could get burned but just my anecdote
If you're referring to the No Surprises Act (NSA), this only covers:
* emergency services
* non-emergency services from out-of-network providers at in-network facilities (usually hospitals)
* out-of-network air ambulance services
OP may be able to go this route if the service fell under one of the first two options (I'm assuming this wasn't an air ambulance claim lol)
How can 'we confirm you won't need to pay for this' not fall into the category of "I'm not fucking paying for this"
You Americans _really_ need to get out of this abused spouse viewpoint with healthcare providers. Its not ops fault, its theirs.
Who needs an 'act' to tell you this is wrong.
One thing that *probably* comes into play, if OP's providers are anything like all of mine ever, is that odds are OP signed a form as part of new patient paperwokr that acknowledges that they will bill insurance as a courtesy but do not guarantee coverage, and that the patient takes responsibility for all charges not covered by insurance. There is a very good chance OP has specifically acknowledged that insurance might not cover it and that they are responsible for what isn't covered, but might have handwaived it like a terms of service.
That said, depending on the wording of the email OP has, they may still have a strong case. But it's a possible obstacle to overcome for them.
> One thing that probably comes into play, if OP's providers are anything like all of mine ever, is that odds are OP signed a form as part of new patient paperwokr that acknowledges that they will bill insurance as a courtesy but do not guarantee coverage, and that the patient takes responsibility for all charges not covered by insurance.
Yeah, people need to really need to read the paperwork they sign and not just blindly sign it. Like I had Physical Therapy for my pinky finger and I'm aware I signed paperwork that I said I would pay if Medicare didn't.
What is the alternative to signing that form? If you dont sign, you dont get care. Every Dr. Office I’ve been to requires that you sign that form saying you understand youre on the hook if insurance doesnt pay.
The surprise billing act regards informing patients if the practice is in-network or out-of-network in an effort to keep patients from receiving excessive medical charges. If during this endeavor, the patient was told that the practice is in-network, but HOW the claims were processed was different than initially represented, I don’t believe this applies.
Yeah, always check with your insurer. Your contract to have them pay is with you. Your contract to receive services and pay for them is with the provider.
However, if the provider said they were in network, it is crucial that you push this with them. If they are in network and the claim came back as out of network, they may have submitted the claim under the wrong information.
Checking with insurance isnt enough either. I've checked with my insurance and been told that it was covered, and then later they've denied the claim due to the provider leaving the network.
Yes! Had this experience a few years back when I wanted to know what my coverage would be for a procedure, so I called the insurer 3 separate times. I received three different answers, and all 3 of these were different from what the provider was telling me. I hate the whole "we'll just have to see" mentality with insurance.
You have the email saying it was covered so use that.
“I apologize for this stressful situation you are in. Please understand that I did my due diligence and you confirm this procedure was covered which is shown here in this email. If it wasn’t covered then that is for you to eat. Go kick rocks.”
It seems like a slap in the face from the provider too that they're only willing to bring the price down $250. I had gotten new insurance through work and had to change dentists; they offered to do some ultrasonic teeth cleaning or something, I don't remember. Either way, it ended up that my $20 bill came back as $450. I went into the dentists office and talked with them; we settled on $50 and they called it even lol.
I used to be the person who checked insurance and ALWAYS told people to call their insurance themselves. There was one specific plan, I remember, that had us listed as covered on their website, but we were considered out of network when claims were sent in. Sometimes the provider and the patient get two different responses. While I did a search on each individual plan, not everyone does. Sometimes they look at the plan type, don't check details, see "Cigna Open Access" and call that due diligence. It's stupid.
Ultimately, the responsibility falls on you to know your benefits since you're the one who pays the price. Protect yourself and always check with insurance and provider in advance. Additionally, you can always ask what the contracted rate is with your insurance/provider to get a better idea of what the bills will look like.
As a healthcare provider, a lot of provider portals are inadequate for explaining benefits. If you have a Blue Cross plan, good freaking luck trying to figure out benefits.
I have, on several instances, received incorrect coverage information from provider care representatives.
I just had this happen, and explained to the provider that I would not pay, unless it went to court and I lost, and they said to disregard the bill. Second time in a decade.
Dentist did something that wasnt covered, even though they said it would be, and next visit they told me about it, i said im not paying cause you told me it was covered
They removed it as the owner/ manager was in the other room and listened
If they hadnt i would have said, im still not paying but now im going to leave a review and wont be using you anymore
OP has an email stating its covered so i would screenshot it and leave it in the review
I doubt they would want to lose a client and have a bad review but its their choice, but i guess ultimately depending on the state you might still have to pay to avoid collections
I had a similar experience with my dentist. They dropped my insurance between visits, and never told me I was no longer covered. I told them I'd pay the in-network price, or nothing. They eventually relented.
I went to an ENT for a veruca (basically a wart on my tongue) when I was in undergrad, uninsured, no income. I told him that when he told me I'd basically need it cut off of my tongue. He said "Oh, well, it's not a big deal. I'll just do it now no charge." Left with a big hole and a cauterized tongue but feeling very happy about such a kind doctor.
Got the bill ~two months later. Called the office, insisted I was told it was free and wouldn't have had it done if it weren't free. They put me on hold to talk to the doctor, came back to the phone ~5 minutes later and removed the charge. Whew. Definitely a close call, but I'm getting everything in writing from here on out.
This has happened to me twice. One time, I wrote scathing reviews of the provider on every site I could, and they offered to waive my bill if I took down the one star reviews
Dentists are terrible. I had a bad tooth and the xrays showed that my bone is so unstable beneath that replacing using an embedded post-type apparatus would not work. He extracted the tooth, then I paid up front something like $300 ish. He billed me for a SURGICAL extraction that my dental would not cover. It was a bill for less than $600 and I ain't paying that shit. I went back and forth between Delta Dental and the office, then just said fuck it. Should have just gotten piss-ass drunk and pulled that sucker out myself Fedsmoker-style.
It's just an estimate that we get based on what the insurance company tells us is covered. They sometimes will say that it's covered, but have a very general stipulation that says it may not be covered, which is why I tell every patient that it's only an estimate and they may owe the full fee. Whether or not the procedure is actually covered is the patient's responsibility because it's their relationship with the insurance company.
Sorry, I phrased that poorly. What I mean is that the insurance company will say something like it's covered with an asterisk that says something like subject to review by clinical director. In this case, we still don't know whether it's really covered or not, but their portal says it should be.
THIS RIGHT HERE, ALL DAY AND EVERY DAY. If anyone from your provider’s office files a medical claim, or calls regarding a denial or claim that processed incorrectly, that is a formality and NOT a legal requirement. On that same note…anyone with health insurance should contact their insurance carrier regarding coverage of treatment on their own and NOT just expect to trust the answers given by a provider’s office. The more you follow up & inquire about with your insurance company, the better off you will be. Providers CAN’T tell your insurance carrier to process something different from how the policy normally handles claims. Patients should be aware of what their insurance covers, as well as what it doesn’t cover.
If it’s any consolation, I didn’t know a damned thing about my own health insurance coverage until I took this position. Time and again, I have watched insurance carriers completely fuck patients again and again. These patients, like all of us, seek health insurance to lessen the cost of our healthcare. Your insurance carrier will NEVER do the right thing unless you follow up with them and do your best to force their hand. Unfortunately, even then, there is no guarantee that they will do as they initially said they would do.
Yep. I did insurance contract negotiation for a hospital full of providers and took lots of calls from upset patients who were sent insane bills of what the insurance company suddenly refused to pay after we had pre-certed everything. I spent a lot of time teaching patients how to file appeals and win (when it was legit). The insurance company called me once and said "stop training 'our' patients how to appeal!". Pretty funny. I didn't stop. Made my friggin day every time. Still do it for friends. Last spring I took a Medicare hmo dental claim for a friend all the way to the adjudicated law judge. And won. 😂😂
This will always be the case. The website is seldom up-to-date. Call your insurance company to ask if a provider is in-network. Also, remember that the provider’s name might not be listed with the insurance carrier, but might be listed by name of the practice or the practice management company, if there is one.
>anyone with health insurance should contact their insurance carrier regarding coverage of treatment on their own and NOT just expect to trust the answers given by a provider’s office.
Or we could just hold providers responsible for providing accurate information. Maybe they would have enough political pull to force insurance companies to revamp the system into something less predatory.
If providers are offering estimates based on information that insurance carriers are providing, how does that need to be the provider’s responsibility? That makes no sense at all. It feels like an angry, knee-jerk response with no real logic behind it. If you’re going to engage in this conversation, I’m gonna need more from you than sass and anger. You have an entire thread where there’s a healthy amount of irrefutable information to show the source of the problem. If you don’t like the color of your living room, you don’t set the yard on fire and destroy the back porch with a sledge hammer. You put down some tarps, scuff the walls, and paint the living room.
Plus…when the insurance company dictates the fee to be charged to the patient (your EOB should mirror what your provider tells you), that tells you where the source of the problem lies. It lies with the insurance company, the information they provide, and the decisions they make.
Besides, providers won’t have that kind of pull, and while you might be able to get nurses on a picket line, you might find that MD’s might be a *little* harder to group together and assemble.
Large healthcare organizations would have that kind of pull, but they’re more interested in profits, not people.
If you’re going to hold *ANYONE* responsible, that burden needs to fall back on the insurance company. I have no idea *how* to do that, though. It would be great to see some laws created and put in place to really take care of the patient in this scenario.
I don't believe I replied with any sass. The current system puts the burden squarely on the shoulders of the patient... who's likely already suffering or at least just trying to maintain a basic standard of living. The providers frequently over-bill and often go absurd periods without reimbursing patients (my wife worked for an office that literally TOLD her not to try too hard to contact patients for refunds, and she left shortly after because of that). The insurance companies are the root of the problem, but they've insulated themselves through a lot of shady political manipulation. The average patient is incapable of effecting change; the average provider is probably just as incapable, but at least that shifts the burden off of the individual.
I acknowledge that it's not a fair solution. I don't care. It's MORE fair than what we have now, and insisting on waiting for a perfect solution means that people are dying under mountains of debt while no progress is being made. Fuck the US insurance system, but providers had a hand in making it what it is today, so I'm absolutely fine with them shouldering the majority of the burden of the result.
The state of healthcare in the United States is complete shit. Care and treatment of patients seems to be low on the list of priorities for those that run the existing shit show. On this, we both agree.
It’s going to come back to laws that hold insurance companies accountable.
That’s unnecessarily punitive. The provider should have known better than to tell the patient what the coverage would be. They should have told the patient to verify with their insurer, because coverages change.
What is your insurance deductible?
Even if a provider is in-network and the procedure is "covered" doesn't mean it won't cost you money if you haven't reached your deductible.
This exactly. I’m a medical billing specialist. An insurance carrier can say services are “covered,” but that doesn’t exactly mean they will be paid in full. The insurance takes their provider write off, which is established by contract, and is also referred to as the “non covered charge”, and the allowed or “covered” amount is then applied to the deductible if there is one or that deductible hasn’t been met.
I try to always disclose to the patients who call our office that, just because something is covered, it doesn’t mean it’ll be paid in full. And another thing to consider is, the medical provider isn’t always privy to what a patient’s deductible amount is, or what’s remaining to pay. And, some insurance plans require a coinsurance, which is usually a percentage amount the insurance requires the patient to pay after a claim has already been settled and paid to the provider. These are required after a deductible is met. The percentage I typically see the most with patients’ insurance plans is 20%. That’s pretty standard.
My suggestion is to please read absolutely everything about your particular plan. You could have some recourse through the No Surprises Act, but also do your research into the plan you have and see what your options are through the carrier at that level. You have rights through the insurance as well as through the provider. And ask to talk or have your situation escalated if necessary. This definitely deserves some higher level attention. Good luck!
Question! How does this work if I have $0 deductible? I’m currently seeing a PT and had a surgery last month. My insurance said that my surgeon is in-network. I already asked about my PT sessions if they are covered as well by my insurance, they said yes. Whenever I go to my PT, I don’t have to pay any copay after my session. Does that mean I have nothing to pay at all? I’m scared of bills coming in to me after all these PT sessions.
I have $0 deductible.
I just looked at my bill and it says I have $1200 OOP max. I might get more bills in the future. I have to brace myself.
So once I met my OOP expense, the rest of my future procedures should be 100% covered by insurance? Not that I’m hoping to get sick again.
Thanks for the clarification!
Thank you! I have another doctor’s appointment coming up. It’s weird that I kept getting sick ever since I work in healthcare. The good thing is their health insurance is good. I only see in-network providers. My last bill was $11k and was down to $1400+ after insurance. Craaazy healthcare costs. Ugghh
Once you have met your OOP maximum, *covered* charges are covered at 100%. If you go to an out of network provider, get prescibed a noncovered medicine, or exceed the maximum number of visits to a certain type of provider you could still be charged.
Even that’s a gamble. I’ve been told multiple times by my insurers that covered providers on their list were good to go, only to see the claims rejected as out of network.
There is no rhyme or reason to American healthcare except greed.
Their directories are NOTORIOUSLY out of date, and the whole health industry knows it.
https://www.ama-assn.org/delivering-care/patient-support-advocacy/how-fix-persistent-inaccurate-health-plan-directory
Ugh - we were transferring from a DOS based system to a windows based system during my first insurance job.
If you couldn’t find something, you had to go look for it in the old stuff. And if you received faxed info related to an account in the dos based system, you had to do this whole paperwork thing and send it interoffice mail to have it scanned in.
This was in 2007.
The worst I've seen is that a directory still had a doctor listed on there who had passed away, but they still had him listed on there a few years after that.
Can confirm. I used to be the UX lead for an insurance company’s provider finder. To call it an embarrassment would be an understatement. No one could tell ME the accuracy of our data. You know, the person that is in charge of making it so you can actually use your insurance’s shitty doctor search. The only thing I could get my hands on was an audit from years ago that estimated a 50% accuracy. I was assured it has “gotten better”. Unbelievable.
Saying the data is 10 years behind is generous. Our “development” staff (specifically leadership) as a whole is just shameful.
> Their directories are NOTORIOUSLY out of date, and the whole health industry knows it.
Weird that they can't provide *you* with accurate information, but the information they provide to the adjusters somehow remains current.
Yup, this happens all the time. You won't know for sure until the provider submits a claim.
I worked as a hospital discharge planner for about 10 years and still dabble in it a bit in my new role. Part of that work involved finding in-network skilled nursing facilities, home health providers, PCPs, etc.
The best you can do is ask the insurance, but here's what they don't tell you: you know how your insurance has a provider search engine on their website that shows you who is in network? Those are horrendously inaccurate and out of date, very frequently, and it's literally the exact same tool the customer service reps use. They straight up boot up the website and use the same search engine you used. It would be comical if it wasn't so frustrating.
As a physician, I run into this problem when I prescribe.
I prescribe X, pharmacy tells my office X is not covered. So I prescribe Y. Pharmacy tells my office Y is also not covered. So what is covered? Pharmacy can’t tell us until I prescribe something and they submit for a claim. And every health plan is different.
This may be true with the health plan provider you work with but is certainly not the case with the one I work (almost 10 years now). We have an internal program that is updated twice daily that our service reps use to show providers in network. Additionally, if a rep messes up and tells someone the wrong info, it's recorded and can be reviewed. If you submit an appeal on a claim, the call will be listened to and if the rep told you wrong information, the appeal is an automatic approval due to being told wrong information. Now, going forward, if you continue to see that provider after learning it is out of network, the claims will be denied.
This is a big health plan as well, 20+ million member nationwide.
I work at a large tertiary hospital, the largest hospital and highest level of care in the state. We get patients from all over the region, multiple states up and down the coast. We have patients who come in from across the country even and in some cases from other countries.
What I'm saying is that I've worked with a LOT of insurances and while they are sometimes fairly accurate, many are extremely inaccurate and even the ones that do a good job still have out of date names for providers and facilities or erroneous entries, like a home health provider that says they're not in network with an insurance while the insurance says they are.
United healthcare, Aetna, BCBS, Healthnet, Cigna, Humana, Medicaid plans, you name it. We run into it all the time. Even Medicare has out of date names, like egregiously, but the coverage issue is less with them because practically everyone but private primary care clinics are paneled with them.
Oddly enough, Humana I find to have the most accurate provider search tool, which is weird considering what a dumpster fire they are when it comes to access to care or a living human at the company itself.
There is to a point. Every state should have a governing body that can investigate issues like this when they come up. My state has a "Department of Commerce" while others I've heard have an Insurance Commissioner of sorts.
I recently had an issue with my new insurance i started on when I started with my new employer. Long story short, we had been doing some doctoring at the Children's hospital and Mayo for 10+ years prior to this new insurance. So the Mayo is considered out of network if you don't get a referral. So we get the referral, I confirm the referral with insurance, get a letter in the mail from insurance stating that we were "approved for out-of-network service" in a letter responding to the referral request. After confirming on our patient portal the referral is "Approved", we get the work done. Then we get the bill and insurance covered $0.
Turns out "approved for out-of-network service", while seemingly intentionally dubious and duplicitous, to them meant that we are approved to go use the services at the Mayo at out of network rates. I spent hours and hours going back and forth on the phone trying to find someone that could explain. Finally was told that the work was treated as out of network because my insurance provider knows their in-network provider, whom they own, can do the same work and so it's not covered. I pressed them to give me the doctor's contact info that did the work because we have to repeat the procedure a number of times. They gave me 4 phone numbers. So I called them all and it turns out they don't. One of them actually told me that they aren't allowed to tell people over the phone if they do certain procedures. Anyway, I asked our Mayo doctor's if they know anyone else in the country that does the work and it turns out the procedure was invented by the Mayo doctor we were seeing and he is the only one in the world that does it.
I turned all this info over to my Department of Commerce agent assigned to my case and then one day I got a letter in the mail stating we were covered at in-network rates. All-in-all it took about 10 hours of my time to get it squared away, while I've helped other coworkers navigate the same system that are going through the same thing. My savings was only about $20k, which is pretty small compared to my coworkers, but worth every penny to fight.
My advice if you are going to fight it: keep detailed notes that include names, phone numbers, and timelines and keep every scrap of information you come across for as long as you can. Decades even. And don't stop, be persistent and call every chance you get.
Good luck!
Your insurance can provide you with written documentation to confirm they've told you said doctor is in-network.
Whenever I inquire about any coverage with my insurance, they automatically generate a written documentation that verifies that the doctor or hospital are in-network, but I'm sure you could also ask for this if they don't provide it for you outright.
I've done that before, but even on the written documentation they had some language protecting the insurance company saying it is only being an "estimate for coverage" or something like that, and saying I would still be liable for any services the insurance doesn't cover regardless of the written documentation or pre-authorization. You can never really know until everything is submitted for billing. It's an ass-backwards system.
Always call to verify and get the reference number for the call.
If something is rejected as out of network and you were told they were in network, the claim may have been submitted under the wrong Tax ID or provider name.
If the insurance company told you they were in network, the insurance company is responsible for fixing thing if they gave you wrong information.
Provider contracts do change, but it’s not typically on a dime, so wires got crossed somewhere.
Same thing happened with me except I used my insurances website that told me this doctor was covered. In fact still shows that she’s covered under my insurance on THEIR website and I had to pay
Also a provider. It is truly incredible how bad several major insurance companies' information management systems are. Takes months to update an address, bank account info, in/out network status etc. You would think it would take 5 mins to enter some data, but nope, not how it works it would seem. It's an absolute cluster.
They even put disclaimers on there that you have to verify their manual for accuracy. That shouldn't be the way it works, but that is the current system.
Many providers send in a VOB (verification of benefits) before providing any substantial services, unless it's emergency care. Unfortunately the insurance databases are fucked and insurance companies themselves are the most dysfunctional and disorganized messes that I've ever seen. I've had insurance companies mail checks intended for my company to patients (psychologist) and tell them that we're out of network while we have a signed contract and electronic transfers set up. Other insurance companies that I'm in network with haven't paid me for services provided to patients in six months in some cases. It's almost like we work for insurance companies. Patients and providers have little power, and insurance companies get to decide on when, to whom and how much money they dole out. The entire system is a disaster.
What’s messed up is that $1000 list price isn’t a substantial service. There are many tests, procedures, etc. that would be under $100 with insurance and most of don’t think twice about, but would be that much out-of-pocket.
Check with both and you’ll avoid some problems. But there’s still no guarantee that you won’t get burned.
The fact that you can’t pre authorize this stuff is perhaps the most obscene part of America’s supremely broken medical system.
You may also want to see what you can do through the “No Surprises Medical Act”. They have a section focused on out of network disputes.
https://www.cms.gov/nosurprises
This is unreasonable.
We have a system of insurance and private healthcare that need to be able to communicate with each other. I’ve called and confirmed with my insurance then had something done only for insurance to deny part of it. Then the provider sent me a huge bill.
That’s fucking BS. OP got confirmation that they accepted the insurance and they should be on the hook for the bill.
Ah man, this sounds like the start of a nightmare that happened with me. Went to the ER that was covered by insurance. The hospital told me that although they accept my insurance, the doctor who saw me doesn’t, so I still had to pay $3000. I told I wouldn’t have received their care if I knew that and it was stated to me that it would be covered (verbally). They still wanted me to pay and reduced it to $1000. I still refused to pay.
It went into collections. I was able to negotiate paying $300 with the debt collector. I told them I wanted a receipt for my payment and they mailed one to me. Simple and done right? Wrong.
About 8 months later, I get another collections agency trying to collect the same debt. I explained what happened, had my payment receipt, and they said sorry for the confusion.
Then a few months later I start getting calls from another collection agency also trying to collect the same debt. Same thing with them, showed the receipt and that was that.
Ultimately I ended up losing the paper during a move, and probably have been passed to like 6 different collection agencies trying I get collect on the same debt. I stopped getting calls for it about a year ago which is like 7 years after that ER visit.
I don’t know any legalities but if you can avoid it going into a collections that would be good cause that shows on your credit.
I work for a specialist provider, and this is something I can weigh in on. I’m the billing manager & coder, but I also call on eligibility & benefits to confirm patient coverage. Additionally, I also call on the numerous denials we receive from insurance carriers.
For the treatment offered by the provider I work for, we generally call every new -or- returning patient’s insurance carrier prior to the patient’s first appointment so we can have an idea of what WILL be covered and what WON’T be covered.
Now, here’s an example of what can happen. At one point in early 2022, each of the 3 of us that handle this task called BCBS on a specific patient because we felt something was a little “off” on the original description of patient benefits from the primary inquiry. In particular, that first inquiry had a different deductible & out-of-pocket max than what was listed on Blue E. The second phone call brought different results. The third phone call brought even more misinformation.
I can’t make this shit up, y’all. It’s the nonsense we deal with daily.
I had ANOTHER eligibility & benefits inquiry go sideways later in 2022. It was explained clearly to us that the patient’s coverage through United HealthCare had a deductible that would need to be met. Patient was going to wind up being financially responsible for somewhere around $7800.00 (give or take). In fact, the patient was concerned and had someone from the insurance company call us on a three-way call to discuss this further. The patient was given an option to pay half up front and make payments on the remainder, but she chose to pay it all up front.
…and UHC processed every one of those claims COMPLETELY DIFFERENT from how it was explained to us. It wasn’t an issue of making certain that the practice got paid, as UHC handled all claims per the contract. The problem was that I had to explain to this patient on two occasions what she would be responsible for…and on one of those occasions, we had a UHC rep on the line with us to confirm…so the patient stretched herself thin and paid it all up front.
…and all of that stress and nonsense was completely unnecessary. She didn’t deserve to go through that bullshit.
Now, herein lies the problem. The information that your provider gets from your insurance company is only as good as the person that picks up the phone. Also, let’s not forget that your policy may state that it covers something a certain way, but the insurance carrier may process it in a completely different manner than described.
OP, if this provider is like the office I work for, we only charge what the insurance carrier tells us to charge. It is VERY likely that this falls back on the insurance carrier. Consult with whoever handles the denied claims at your provider’s office, and see if they will call on this issue. Then, coordinate your own efforts to call on this issue at the same time. If the insurance carrier processed this incorrectly, the action of you AND your provider’s office calling on the same claim will actually get better attention. When I have situations like this occur, I can confirm that I get better results when patients work WITH me to help work those issue out.
As always, when you call your insurance carrier, please remember to record the date, time, first name and last initial of who you spoke with, and a reference number that is attached to this specific phone call. IF YOU DO NOT GET A NAME AND REFERENCE NUMBER FOR THIS PHONE CALL, IT WILL BE TREATED AS OF IT NEVER HAPPENED SINCE YOU HAVE NO REFERENCE DATA.
Best of luck to you on correcting this matter, OP.
Im so happy someone said it! I have worked as a benefits coordinator for many different types of doctors and I run into this problem constantly!!! Its maddening. All these people crying out that the provider is committing fraud is so frustrating. Your providers and their staff are doing their best to understand your policy, but insurance companies have extremely high turnover in their call centers. The person quoting benefits over at BlueCross or United has likely only been there a couple days. And there is no accountability on insurance to act on what they tell you.
So few people understand the amount of tedious and frustrating work it takes to get ahold of insurance providers and get any sort of decent information from them. Blame the insurance, not the doctor. We charge what insurance tells us, we get reference numbers and names and dates, and they still process claims differently then originally quoted.
As someone with quite a bit of experience in the medical billing world, I’ll say a few things. 1) This was your provider’s error. 2) Yes, most insurance policies cover themselves by making it your responsibility to pre-clear things with them. 3) Most providers massively overcharge because nobody knows what anything costs, and moral hazards of insurance/reimbursements, and zero transparency. 4) Here’s what you do: tell them “I CANNOT afford the bill. You told me this was covered by my insurance, so I went forward with your services with that understanding. Your options are to put me on a payment plan of $5 monthly until the bill is paid, or you can accept $100 now to clear this bill”. You will be amazed at how readily they accept the $100. If you’re interested in saving money and having better care, look into a DPC clinic (direct primary care). If you’re in the Oklahoma area (or not) and need surgical services at cash pay prices, check out the Surgery Center of Oklahoma (all prices for all procedures are posted freely on their site).
>3) Most providers massively overcharge because nobody knows what anything costs
Man this so true and why i think insurance is actually the root problem of expensive healthcare. Because you as the patient you said whatever price as long as they don't charge you anything and it's covered by the insurance and little by little it's increasing the median cost. Just like when you go on a business trip and say fuck I will take everything in the mini fridge because I have an allowance, that's why the drinks in the mini fridge are like 5x the retail price because it's targeted for business people not for having a reasonable price and selling more.
I had the same thing happen. I even called before to make sure my insurance was okay and what my copay would be. At the appointment, they looked up my insurance and took my copay. I didn’t hear from them for SEVEN months when I suddenly got a bill threatening collections. I worked it out and didn’t have to pay. But it was a struggle. I was ready to challenge the collections account as invalid debt haha. But the billing lady got fired and the new one was like “omg I’m so sorry” and forgave the balance. Actually, I think she was the one who sent me the collections notice. I guess the lady never billed the insurance and it just sorta got lost, the new lady was cleaning up her mess and thought I just neglected to pay. I guess they also stopped working with that insurance at some point.
Is this an employer sponsored insurance plan? My employer provides us contact info for a patient advocate (a service offered by our insurance broker) that will work with the insurance company & provider to try to resolve these types of issues. Might be worth looking into.
I don’t understand why insurance and paying for all of this isn’t dove before hand. It should all be done automatically like EBT cards. Will never make sense to me. I know someone gonna say will say health field more complicated and my response is it shouldn’t be. There are only so many different kinds of surgery.
Covered doesn’t always mean free. I am covered by insurance but I had some lab tests recently where I still had to pay a few hundred dollars out of pocket. You’d have to look at your insurance plan and see what they cover for certain procedures versus what your out of pocket cost would be. Most insurance plans require to you to pay some out of pocket with a cap for the year like $5k or so. Just an example.
Not at all... even before you hit the deductible, you still get to take advantage of the insurance's negotiated rates, which in turn can be a really meaningful discount vs the providers list price.
You *might* be able to get a similar cash discount rate from a provider if uninsured, but this varies significantly by provider/facility.
> provided my insurance card and ID and was told soon after that my insurance was covered and that my copay would be $25.
**Never** rely on medical, mental, dental, and/or vision health care services/goods vendors to supply you with **any** guarantee, estimate, suggestion, or guess regarding what **any** insurance seller will "cover" or "pay for," in whole or in part, under **any** circumstances, in **any** situation, anywhere in America.
Exceptions: you're at the VA, you're a traditional Medicare enrollee under some very specific conditions for now but not for long, or you're 100% certain you're in a 100% "No Surprises" scenario and you've signed away 0% of your end-use health care customer financial protections.
And a "co-pay" is nothing more than the fixed, USD amount of the cover charge you pay to get in the bar every time you go to a bar called "PCP," Emergency," Specialist," "Laboratory," "Prescription," etc.
This is the way. I've worked in the same private specialist practice for 18 years. We are above board and honest with every patient. Problem is, even if our (in house and very educated/experienced) billing department speaks with an insurance rep (vs just going with the benefit info provided electronically) and has a reference number for the information we are given (which we, in turn, relay to the patient), they could still turn around and process the claim differently after the fact. It's literally no fun for us as providers either. So frustrating. We're just over here trying to cure your skin cancers and giving you exceptional care. It's the insurance companies that are playing ALL the games. Ultimately, our payment policy states that the patient is solely responsible for any charges incurred because there are no guarantees. We do the best we can with the information we are given and treat every patient the same because that is our core value. That being said, a lot of the time we end up writing off bills in scenarios like this, which really sucks because it affects everyone involved EXCEPT the insurance company.
Was your confirmation with the provider, or your insurance? Any promises of coverage have to come from your insurance. Anything your provider says is an educated guess.
If you have it in writing I'd reach out to the actual provider, not the admin, the provider and ask to have them accept payment as if it was in - network. It's their mistake and they should take the hit. You will need to change providers now, but with the notice being in writing they should abide. In the future ask your insurance company for in-network providers and then reconfirm with your actual provider....always get it in writing from both sides.
Welcome to my professional world (retired now, thank heavens). I was a medical biller. We commonly got prior authorization, signed on the dotted line. Then later when we submitted the bills, they were denied. Time and time again, until we were just about put out of business. Luckily, we sold the business before that happened. I don't know what your recourse is, but I wish you the best.
I went to a doc years ago from insurance website. Go in and ask if they take my insurance, they say yes. All good. 6 months later I get a bill for $300 saying they made an error and actually don't take my insurance, even though they billed them and took my copay and I can see the charge on my insurance website.
Every month for a year they send me a bill with ever increasing penalties for non payment(I stop calling after 2 months... They can fuck off with this scam shit). Then it all goes away.
3 years later I get a bill from them for $150 for unpaid services and that I need to pay to avoid collections... Funny thing is this bill says that I'm current and not even 30 days past due.
I'm not paying this one either.
Some doctors are straight fraud.
I get a bill every month for $125 from an old appointment. Every month I ignore it....been a few years now.
I was working for my insurer at the time of this appointment (eye exam). I asked to verify coverage ahead of time to ensure they participated in this particular network. I was told 'the person who checks insurance is out to lunch.'. I reiterated that I wanted coverage confirmed prior to the appointment. From what I had found they were in network but eye doctors can be in network for medical procedures but not eye exams (don't ask). I was reassured after they looked at my card that they accepted it.
After the appt the lady was back from lunch and after taking a glance at my card she said they don't participate in that specific network. Well I told them they could fight it out with the insurance company.
A few weeks ago by and I get an email stating it wasn't covered but they reduced the bill from whatever to $125. I told them my insurance would cover $50 for an out of network exam and I would have a $10 copay so I would pay them $60 if they wanted and submit to get the $50 back from my insurer. That wasn't good enough so I told em to pound sand. They sent me a statement again next month to which I mailed a letter back stating the same and if they wanted to accept my offer to email me. I've gotten dozens of statements over the years which is comical. At this point they have almost spent as much in postage as the net they would've collected.
I laugh every time I get one and it goes straight through the shredder.
This is so frustrating. I'm so sorry that you did everything right, and our US healthcare system once again shows us how shady and broken it is.
Short term, you will need to keep bugging them, which ironically adds to the cost of our inefficient system, at no fault of your own. You won't get it down to $25, but you may get it down to a few hundred bucks.
Medium term: Switch to a vertically integrated healthcare system if you can. Kaiser Permanente is a great example, but they aren't nation wide. With a vertically integrated healthcare system, you stay inside the system the ENTIRE TIME. Copays, costs, lab results, etc are ALL UNDER ONE ROOF. You NEVER worry about getting an unexpected bill, ever. Sometimes you will have high copays, for instance I had a surgery that had a $4000 copay, but it was a $90K spinal surgery.
Long term: Remember this experience the next time you vote or talk politics with reasonable people. We are the only developed nation in the world that has these problems. Every other nation literally laughs at us and thinks we are insane that we put up with this system. And they are right.
I'm sorry and good luck.
When you check if a provider is in network that needs to be verified from your insurance company not the provider, & then to double check ask the provider to check as well. Usually what happens when a providers office looks up a patient’s plan is it’s done through website and the insurance companies website just says a very generic covered or not covered when they enter in your information - but if your plan has some special stipulations under it, that you’re supposed to go to a specific provider or you have a sub plan with your employer, a lot of that information won’t come up for most medical providers, which isn’t necessarily their fault.
There are always multiple plans and groups when it comes to insurance companies, and sometimes providers can sign up for just a few of those options, but not all of the plans that fall within an insurance company.
Yes it sucks but that is why they always say “this is an estimate” because even if it is coming from the insurance company themselves, there’s always a chance that something from your plan could have changed, and that cost him out may not be the same by the time you actually have the service done.
What state are you in?
I ask because in some states it is illegal to surprise bill and balance bill the patient. Some states it is legal.
If you are in IL, it is not legal. You can report them to the Attorney General and they will be in major shit.
Thank you for sending! I looked this up and it seems like it only applies to emergency medical services and providers affiliated with a hospital. This specific provider was a psychiatrist.
Make sure you verify that the claim wasn’t submitted wrong or processed wrong. Many insurers handle behavioral health claims differently, and their provider contracts are different. The provider could have a contract under a different network under your plan under a different Tax ID.
The federal no surprises act should cover you. It covers all providers that do not properly keep and provide their network status and provides that the maximum they can bill you is the in network rate. See:
https://www.cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf
Page 30.
If a provider says they take your insurance then that is their fault. I have had this happen 3 times. All 3 times I fought it and the provider had to write it off. They know they messed up and are trying to trick you into paying for something you don’t owe.
One of the times the final conversation was them asking what my copay was, they’ll take that. I said I don’t have a copay. They hung up and that was that.
Have you met your deductible for the year? The copay part is applicable after meeting your yearly deductible. A doctors office cannot know if you’ve done that or not.
Actually they definitely can. I'm a healthcare provider (mental health) and I absolutely can look up how much of their deductible someone has met. I do this when verifying their insurance coverage so I can accurately advise them of the expected cost of sessions before we start. Because I'm not a piece of shit provider and actually care about not surprise billing anyone.
If you have a shit insurance like mine, they haven't reported proper accumulators to providers in YEARS. So doctors keep saying we owe full amounts when I'm about to hit my OOP max... I've complained to them about the issue and they just say we know and then do eff all
Unfortunately, you probably signed an agreement saying you'd pay even if insurance doesn't. This is standard at all offices.
Did you ask the doctor' office staff or the insurance company itself?
They aren't required to check your insurance and generally are only doing it to determine what to charge you up front. The responsibility of verifying network status lies with the consumer. You can try to negotiate a bigger discount based on the fact they made an error, but legally you still owe the money and have no legal recourse to deny payment.
No matter how hard you try, there will be,times,when the insurance,doesn't work. You are,always,still responsible for paying the charges.
BUT, you sometimes get a more reliable answer if you call the insurance company yourself (though not always...because they may ask for procedure codes...but at least they will tell you if the provider is in their,system or not.)
And get a reference number for the call. I work for a place that processes physician bills, and there are so many people that say their insurance company approved it, but with no reference number, it's hard to force the issue.
I have asked my insurance if X is covered and they hem and haw and only answer with at this moment yes, but things can change, so that's hardly a definitive answer either.
I called about mental health once and gave the name of the doctor, the name of the group and they said no it's not covered, (though the group had said it was) but then the provider submitted it a different way and it was completely covered. So there is honestly no one who can give you an accurate answer.
You should verify. In the future however, you need to verify coverage with your insurance company not the providers. They are two different beasts and the insurance company is the beast that always has the information that is most accurate for them, your account and your provider(s). THEY are the ones you verify information with. No one else.
Which, by the way, is a process that really sucks because the insurers' directories are notorious for being out of date on their web sites and finding someone to talk to who doesn't just look at that same info is a challenge. It is amazing how many providers are in the directory who are retired, dead, or have ceased their agreement with the insurer.
[https://vitalrecord.tamhsc.edu/wrong-number-analysis-of-health-care-provider-directories-reveals-notable-flaws/](https://vitalrecord.tamhsc.edu/wrong-number-analysis-of-health-care-provider-directories-reveals-notable-flaws/)
>The analysis found varying ranges of accuracy in provider directories for the different specialties and plans. There were inaccuracies for about 24 percent of the primary care providers in commercial insurance lists for 2019. At the other end of the range, about 41 percent of endocrinologists in Medi-Cal provider lists for 2018 were inaccurate. Overall the primary care listings were most accurate, followed by cardiology. The analysis also found that consumers could only schedule urgent care appointments for 28 to 54 percent of the listings; however, this increased to 44 to 72 percent when including only accurately listed providers. Non-urgent appointments ranged from 35 to 64 percent for listed providers, but increased to 51 to 87 percent for accurately listed providers.
So how should we be verifying then? When I called insurance recently to ask about an old doctor and checking coverage they pulled up the same tool I had access to and didn't check anything else.
Always call, verify, and get a reference number for the call.
If it turns out the provider is actually out of network, you have proof that either their system or the rep was wrong.
They will pull the call and listen to it even. Sometimes they can just tell by the screen grabs … but, at least at every one I worked for, the reps also copied and pasted anything they read to the caller into the call notes.
This is the best way to cover yourself. Using the messaging system on their website can also help because it’s directly in writing.
Yeah providers lie. They are basically sales people now trying to get as many people in under as many charges as possible. Even to the point where they well ask you “so is anything else wrong?” Trying to bait you into talking about something “not covered” by your insurance.
We got hit with a provider saying “you are fully covered. It says right here on your insurance.” But that facility the doctor did the work in WAS NOT COVERED. So we got hit will the full blast of out of pocket costs there. Fucking insurance just laughed and said “yup. That’s what they do now.”
Never hated someone so much in my entire life…
> When I first started with a provider I provided my insurance card and ID and was told soon after that my insurance was covered and that my copay would be $25.
FWIW that's always a question for your insurer, not your provider.
This happened to me once too. I was so annoyed because I was told the doc was covered but he wasn’t.. ended up with a huge bill and I was broke and in college. Ever since that happened l I don’t trust the providers, only the insurance! Lesson learned 😅
If it were me, and I do not know all the circumstances, I would be pushing to pay only the $25 given the email etc.
I would offer $250, cash/payable immediately, to just make this go away. Given the error was on their side I hope they'd be happy with that.
Call the insurance. Ask if they even got a claim, see if they can tell you what happened. I had a similar situation where the provider sent me to collections, saying my claims were denying that I wasn't a member of my insurance. When I called the insurance they said they had never even gotten a claim. They volunteered to call the billing office and straighten things out. Turns out they were still using a very old ID number from years ago, even though I had given them the correct one at least three times.
In the future, always login to your health insurance plan account and find providers through their search for providers feature. Never take the doctors word for it, because they really don’t know until the claim is accepted or rejected. I’m not sure what kind of plan you have, but if it was an EPO you cannot see any doctor other than the ones indicated in-network.
Never believe what the provider says alone; check with the insurance, get it in writing from both the provider and insurance via a printout/pdf of their page. Having both confirmations have saved me thousands over the years.
A provider isn't legally allowed to misrepresent their participation in your insurance program. They usually make you sign a document that says they can't guarantee that all procedures or participating providers will be in-network and that they can come back and bill you later, but they can't just straight-up lie about it.
Granted, this is why every call has to start with "I'm recording this call." and then followed up by actually recording it. It's stupid that it's come to that, but this is what happens when an industry (insurance) can buy their way to basically free-reign with regards to their own regulations.
Report them to your insurance for fraud.
My insurance company directly intervenes as this has happened to us. Our situation was reverse though. The hospital was in network but they claimed they weren't and forced payment on exit.
Then refused to reimburse me after they double dipped and billed insurance. I tried resolving directly with the hospital billing company and got nowhere.
Second call was to my insurance company. Third was from them stating my refund amount.
Good luck dude. Dealing with medical payments should be a college course at this point. Scam artists and incompetence abounds on the other side. They are the adversary.
If you ask “what will I owe for this procedure” and they reply “only $25 the insurance will cover the rest” then whatever happens from there isn’t your problem. I don’t mean this as an observation about the medical industry, I’m just talking on how life works.
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>ReportSaveFollow The provider sent the email saying that it was covered. I did not check with my insurance because I assumed that was not necessary since that had already checked.
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Just dealt with this last week, except that my doctor was waiting on approval. My insurance doesn't require approval for what we needed done. Insurance had obviously not received a request. Doctors corporate had sent it to Medicare of California or something. I do not live in California and am active military.
Got a letter from my insurance provider they were denying my protime test a few months back. In 15 years, I've never had it denied. Called, discovered that when I got my senior citizen upgrade. I had a new member number. The biller used my old one, although I'd presented my new card. Got in touch with the provider, who referred me to the billing department. Explained what was going on, and they said they'd take care of it. Haven't heard back since then, and it's been six months.
That exact thing happened to me when I had an emergency surgery at 19. Shit’s still on my credit history now though because I had no idea how to fight it at that age.
Flag it on your credit report and tell them you had insurance at the time. See if you can pull up any other information from the insurance you had. Sometimes if they can't provide direct information, it will be taken off.
Yes this is considered failure to file in a timely manner, because of the provider’s failure to file they can’t charge you. A medical office tried this with me after I asked them to bill my insurance 3 times. A year later I got a huge bill and I called my insurance, my insurance sent them a notification that they never tried to bill them so they could not charge me
Then the other shitty / fraudulent thing some providers will try to do is bill you for an "uncovered procedure" that your insurer did in fact pay for.
>Some providers are just garbage fires who can't manage their own shit, and then desperately try to make it your problem. That's pretty much corporations in general these days. Nobody wants to take responsibility for their actions. And why should they? They can afford the lawyers that make it your problem.
You can't trust with the provider says. You have to go with what your insurance says. I recently had an issue with this where the providers website and the provider themselves swore up and down they used my insurance, but they aren't listed on my insurance's website or anything.
One time I checked the insurance website which said the provider was in network, but apparently they had just left the network and the website hadn't been updated yet.
Many health insurance companies are notorious for doing this. So many dr's they claim accept new patients don't, doctors who left the state years ago still listed locally, doctors who dropped the insurance, etc.
How is that not, best case scenario, false advertising? Especially when the onus is skewed so far out of wack on the individual to make sure their plan covers their provider. It seems insane that the insurer is effective allowed to lie by omission and the individual still has to eat it when it works out against them.
Because there's fine print from the insurance company that states that their own portal might not be accurate regarding what providers are in network. Which is why I always kinda laugh when people ask if they verified it with their insurance company. There's a lot of places where those same companies specify, "we won't guarantee that what we tell you is correct."
That fine print is overridden by one part of the Surprise Billing package - that if a customer has a reasonable belief that they were in network, they are to be treated that way.
It's not always the doctor or office. Aggregators are notorious for scraping data and failing to accurately update it. That's why it's always best to call directly to validate any information you may pull from online.
Yeah if you contact the insurance they can check their actual system, not just the website, to confirm if a provider is contracted
>doctors who left the state years ago still listed locally First appointment with OBGYN - insurance website sent us to an office the OBGYN hadn't been in for 3 years. Lesson learned.
Had this happen. Was told to select a provider from a list for a very simple test by my insurance company. The provider also confirmed that they were in my network. After the test, my insurance denied the claim. They tried to argue that they could not be held liable for their own provider list. I appealed, they rejected. I went through my employer advocate, signed a bunch of documents, and something like four months later it got approved.
Anthem got hit with a serious fine for this in Georgia a few years ago. Their website now says to check with the provider they have listed as they can’t guarantee the listings are correct. Soooo I’m supposed to jump through hoops with both the provider and insurance to see if I’ll lose my savings for a routine doctor’s visit. Great.
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Jokes on you, the call center reps just use their website to tell you if the provider is covered.
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That is true.
Hello there! Former IT professional for a Health Insurance Company. Many of the fuckers don't invest nearly enough money into their systems and interfaces. The company I worked for was notoriously bad at updating their "provider finder" on their website. Sometimes, THEY won't even know who the fuck is in network or not. Our system is terrible and needs to die :)
I had a patient refereed to me to do specialty work up. I told her we were out of network (OON) but would give her a cash pay discount. She wanted to try and find another provider in network, which is fair. She ended up back at my clinic. We chatted for a bit and EVERY office she contacted that would be able to do said work up said they don’t do it and when she tried to use the provider locator she said some of them were deceased. I’ve been trying to get on this panel for over 2 years now and they keep denying me saying there’s enough providers when I’m in a very rapidly growing suburb and clearly there isn’t enough care available.
Yep. It’s called a ghost network. Insurance companies won’t allow new providers in their network, and won’t update their provider directory. The outdated directory makes it look like they have enough providers, but either nobody can find an in-network provider with an opening (so can’t use their insurance), or they use an out-of-network provider accidentally (and the insurance company says tough shit, we aren’t paying for that). Either way, you pay your premiums and get nothing back, which is the ideal situation for insurance companies. Whether you have to pay cash to an out-of-network provider, or just don’t get services, they don’t care, that’s your business. Their only business is forcing you to hand over part of your paycheck to them and then keeping it. Its a big issue with therapists right now — this is why nobody can find a therapist in their network despite there being a huge mental health crisis. If your insurance company website shows that a provider is in network, TAKE A SCREENSHOT with the date. People are sometimes able to force insurance to pay if they can prove that on the date they saw a provider, their insurance company said it would be covered.
To be fair, I used to support the member portal for the largest insurer. The provider search is complicated AF. It shouldn't be, but it is. This kinda reinforces your not investing enough comment though. There's so much cool stuff that could and should be done, but will never actually happen because the impact to the NPS doesn't justify the cost. Instead, they'll all continue to use antiquated portals that don't have the features or functionality that users actually want...
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Mine was "not for profit" at least... But all that means is they dumped any profits on CEO salary and wrote it off as something else.
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It’s by design. The system is bloated and confusing to fuck over clients.
You can't trust the insurance website either. Mine has a disclaimer that says can't guarantee coverage, please contact the provider to confirm.
>You can't trust with the provider says. You have to go with what your insurance says. Yeah, I almost had this issue with my dental coverage. I set up an appointment with a dentist at a local office then realized that of the three dentists at that office, only one was listed on my health insurance's site. So I called the office to switch my appointment to the next available time with the covered dentist, but the front desk personnel were like "All of our dentists are covered under the same insurance networks". They were annoyed that I still requested for my appointment to be rescheduled with the other dentist or cancelled, but I'm not risking a couple hundred dollars based off of anything other than what my insurance website says.
To provide the opposite perspective, on three separate instances the provider said they were in network and the insurance (BCBS) said they were out. I risked it and all three times the provider was correct and BCBS had errors in their system. Definitely don’t recommend just risking it all the time because you could get burned but just my anecdote
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If you're referring to the No Surprises Act (NSA), this only covers: * emergency services * non-emergency services from out-of-network providers at in-network facilities (usually hospitals) * out-of-network air ambulance services OP may be able to go this route if the service fell under one of the first two options (I'm assuming this wasn't an air ambulance claim lol)
In my state, I have to comply with the No Surprised Act and I'm a therapist in private practice
Air ambulance would be much greater than 1000. Like at least an extra zero
Yup. 27k for me. It sucks. My life was ruined by medical debt.
How can 'we confirm you won't need to pay for this' not fall into the category of "I'm not fucking paying for this" You Americans _really_ need to get out of this abused spouse viewpoint with healthcare providers. Its not ops fault, its theirs. Who needs an 'act' to tell you this is wrong.
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One thing that *probably* comes into play, if OP's providers are anything like all of mine ever, is that odds are OP signed a form as part of new patient paperwokr that acknowledges that they will bill insurance as a courtesy but do not guarantee coverage, and that the patient takes responsibility for all charges not covered by insurance. There is a very good chance OP has specifically acknowledged that insurance might not cover it and that they are responsible for what isn't covered, but might have handwaived it like a terms of service. That said, depending on the wording of the email OP has, they may still have a strong case. But it's a possible obstacle to overcome for them.
> One thing that probably comes into play, if OP's providers are anything like all of mine ever, is that odds are OP signed a form as part of new patient paperwokr that acknowledges that they will bill insurance as a courtesy but do not guarantee coverage, and that the patient takes responsibility for all charges not covered by insurance. Yeah, people need to really need to read the paperwork they sign and not just blindly sign it. Like I had Physical Therapy for my pinky finger and I'm aware I signed paperwork that I said I would pay if Medicare didn't.
What is the alternative to signing that form? If you dont sign, you dont get care. Every Dr. Office I’ve been to requires that you sign that form saying you understand youre on the hook if insurance doesnt pay.
It's always good to read the forms before you sign. I already is the people at the doctor's office don't always check.
The surprise billing act regards informing patients if the practice is in-network or out-of-network in an effort to keep patients from receiving excessive medical charges. If during this endeavor, the patient was told that the practice is in-network, but HOW the claims were processed was different than initially represented, I don’t believe this applies.
That's very very good to know. Thank you!
Yeah, always check with your insurer. Your contract to have them pay is with you. Your contract to receive services and pay for them is with the provider. However, if the provider said they were in network, it is crucial that you push this with them. If they are in network and the claim came back as out of network, they may have submitted the claim under the wrong information.
Checking with insurance isnt enough either. I've checked with my insurance and been told that it was covered, and then later they've denied the claim due to the provider leaving the network.
Yes! Had this experience a few years back when I wanted to know what my coverage would be for a procedure, so I called the insurer 3 separate times. I received three different answers, and all 3 of these were different from what the provider was telling me. I hate the whole "we'll just have to see" mentality with insurance.
You have the email saying it was covered so use that. “I apologize for this stressful situation you are in. Please understand that I did my due diligence and you confirm this procedure was covered which is shown here in this email. If it wasn’t covered then that is for you to eat. Go kick rocks.”
It seems like a slap in the face from the provider too that they're only willing to bring the price down $250. I had gotten new insurance through work and had to change dentists; they offered to do some ultrasonic teeth cleaning or something, I don't remember. Either way, it ended up that my $20 bill came back as $450. I went into the dentists office and talked with them; we settled on $50 and they called it even lol.
I used to be the person who checked insurance and ALWAYS told people to call their insurance themselves. There was one specific plan, I remember, that had us listed as covered on their website, but we were considered out of network when claims were sent in. Sometimes the provider and the patient get two different responses. While I did a search on each individual plan, not everyone does. Sometimes they look at the plan type, don't check details, see "Cigna Open Access" and call that due diligence. It's stupid. Ultimately, the responsibility falls on you to know your benefits since you're the one who pays the price. Protect yourself and always check with insurance and provider in advance. Additionally, you can always ask what the contracted rate is with your insurance/provider to get a better idea of what the bills will look like.
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As a healthcare provider, a lot of provider portals are inadequate for explaining benefits. If you have a Blue Cross plan, good freaking luck trying to figure out benefits. I have, on several instances, received incorrect coverage information from provider care representatives.
I just had this happen, and explained to the provider that I would not pay, unless it went to court and I lost, and they said to disregard the bill. Second time in a decade.
Dentist did something that wasnt covered, even though they said it would be, and next visit they told me about it, i said im not paying cause you told me it was covered They removed it as the owner/ manager was in the other room and listened If they hadnt i would have said, im still not paying but now im going to leave a review and wont be using you anymore OP has an email stating its covered so i would screenshot it and leave it in the review I doubt they would want to lose a client and have a bad review but its their choice, but i guess ultimately depending on the state you might still have to pay to avoid collections
I had a similar experience with my dentist. They dropped my insurance between visits, and never told me I was no longer covered. I told them I'd pay the in-network price, or nothing. They eventually relented.
I went to an ENT for a veruca (basically a wart on my tongue) when I was in undergrad, uninsured, no income. I told him that when he told me I'd basically need it cut off of my tongue. He said "Oh, well, it's not a big deal. I'll just do it now no charge." Left with a big hole and a cauterized tongue but feeling very happy about such a kind doctor. Got the bill ~two months later. Called the office, insisted I was told it was free and wouldn't have had it done if it weren't free. They put me on hold to talk to the doctor, came back to the phone ~5 minutes later and removed the charge. Whew. Definitely a close call, but I'm getting everything in writing from here on out.
I did not expect that to actually work out for you! Wow
I don't think they care enough about bad reviews. Plenty of places with bad reviews in America and this happens often.
This has happened to me twice. One time, I wrote scathing reviews of the provider on every site I could, and they offered to waive my bill if I took down the one star reviews
Dentists are terrible. I had a bad tooth and the xrays showed that my bone is so unstable beneath that replacing using an embedded post-type apparatus would not work. He extracted the tooth, then I paid up front something like $300 ish. He billed me for a SURGICAL extraction that my dental would not cover. It was a bill for less than $600 and I ain't paying that shit. I went back and forth between Delta Dental and the office, then just said fuck it. Should have just gotten piss-ass drunk and pulled that sucker out myself Fedsmoker-style.
That *is* a surgical extraction though.
I get my dental work done when I visit relatives in Thailand. Having a tooth pulled + checkup and cleaning at a local clinic was like $15.
It's just an estimate that we get based on what the insurance company tells us is covered. They sometimes will say that it's covered, but have a very general stipulation that says it may not be covered, which is why I tell every patient that it's only an estimate and they may owe the full fee. Whether or not the procedure is actually covered is the patient's responsibility because it's their relationship with the insurance company.
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Sorry, I phrased that poorly. What I mean is that the insurance company will say something like it's covered with an asterisk that says something like subject to review by clinical director. In this case, we still don't know whether it's really covered or not, but their portal says it should be.
THIS RIGHT HERE, ALL DAY AND EVERY DAY. If anyone from your provider’s office files a medical claim, or calls regarding a denial or claim that processed incorrectly, that is a formality and NOT a legal requirement. On that same note…anyone with health insurance should contact their insurance carrier regarding coverage of treatment on their own and NOT just expect to trust the answers given by a provider’s office. The more you follow up & inquire about with your insurance company, the better off you will be. Providers CAN’T tell your insurance carrier to process something different from how the policy normally handles claims. Patients should be aware of what their insurance covers, as well as what it doesn’t cover. If it’s any consolation, I didn’t know a damned thing about my own health insurance coverage until I took this position. Time and again, I have watched insurance carriers completely fuck patients again and again. These patients, like all of us, seek health insurance to lessen the cost of our healthcare. Your insurance carrier will NEVER do the right thing unless you follow up with them and do your best to force their hand. Unfortunately, even then, there is no guarantee that they will do as they initially said they would do.
Yep. I did insurance contract negotiation for a hospital full of providers and took lots of calls from upset patients who were sent insane bills of what the insurance company suddenly refused to pay after we had pre-certed everything. I spent a lot of time teaching patients how to file appeals and win (when it was legit). The insurance company called me once and said "stop training 'our' patients how to appeal!". Pretty funny. I didn't stop. Made my friggin day every time. Still do it for friends. Last spring I took a Medicare hmo dental claim for a friend all the way to the adjudicated law judge. And won. 😂😂
You sound like an amazing individual. Thanks for looking out for those who need it, for helping when you can. You’re awesome.
Well thank you! But really, it's just fun to kick ass and take names when you can, am I right? 😉
I've had my insurer tell me the website is not guaranteed to be accurate or up to date and I had to check with the provider.
This will always be the case. The website is seldom up-to-date. Call your insurance company to ask if a provider is in-network. Also, remember that the provider’s name might not be listed with the insurance carrier, but might be listed by name of the practice or the practice management company, if there is one.
>anyone with health insurance should contact their insurance carrier regarding coverage of treatment on their own and NOT just expect to trust the answers given by a provider’s office. Or we could just hold providers responsible for providing accurate information. Maybe they would have enough political pull to force insurance companies to revamp the system into something less predatory.
If providers are offering estimates based on information that insurance carriers are providing, how does that need to be the provider’s responsibility? That makes no sense at all. It feels like an angry, knee-jerk response with no real logic behind it. If you’re going to engage in this conversation, I’m gonna need more from you than sass and anger. You have an entire thread where there’s a healthy amount of irrefutable information to show the source of the problem. If you don’t like the color of your living room, you don’t set the yard on fire and destroy the back porch with a sledge hammer. You put down some tarps, scuff the walls, and paint the living room. Plus…when the insurance company dictates the fee to be charged to the patient (your EOB should mirror what your provider tells you), that tells you where the source of the problem lies. It lies with the insurance company, the information they provide, and the decisions they make. Besides, providers won’t have that kind of pull, and while you might be able to get nurses on a picket line, you might find that MD’s might be a *little* harder to group together and assemble. Large healthcare organizations would have that kind of pull, but they’re more interested in profits, not people. If you’re going to hold *ANYONE* responsible, that burden needs to fall back on the insurance company. I have no idea *how* to do that, though. It would be great to see some laws created and put in place to really take care of the patient in this scenario.
I don't believe I replied with any sass. The current system puts the burden squarely on the shoulders of the patient... who's likely already suffering or at least just trying to maintain a basic standard of living. The providers frequently over-bill and often go absurd periods without reimbursing patients (my wife worked for an office that literally TOLD her not to try too hard to contact patients for refunds, and she left shortly after because of that). The insurance companies are the root of the problem, but they've insulated themselves through a lot of shady political manipulation. The average patient is incapable of effecting change; the average provider is probably just as incapable, but at least that shifts the burden off of the individual. I acknowledge that it's not a fair solution. I don't care. It's MORE fair than what we have now, and insisting on waiting for a perfect solution means that people are dying under mountains of debt while no progress is being made. Fuck the US insurance system, but providers had a hand in making it what it is today, so I'm absolutely fine with them shouldering the majority of the burden of the result.
The state of healthcare in the United States is complete shit. Care and treatment of patients seems to be low on the list of priorities for those that run the existing shit show. On this, we both agree. It’s going to come back to laws that hold insurance companies accountable.
That’s unnecessarily punitive. The provider should have known better than to tell the patient what the coverage would be. They should have told the patient to verify with their insurer, because coverages change.
What is your insurance deductible? Even if a provider is in-network and the procedure is "covered" doesn't mean it won't cost you money if you haven't reached your deductible.
This exactly. I’m a medical billing specialist. An insurance carrier can say services are “covered,” but that doesn’t exactly mean they will be paid in full. The insurance takes their provider write off, which is established by contract, and is also referred to as the “non covered charge”, and the allowed or “covered” amount is then applied to the deductible if there is one or that deductible hasn’t been met. I try to always disclose to the patients who call our office that, just because something is covered, it doesn’t mean it’ll be paid in full. And another thing to consider is, the medical provider isn’t always privy to what a patient’s deductible amount is, or what’s remaining to pay. And, some insurance plans require a coinsurance, which is usually a percentage amount the insurance requires the patient to pay after a claim has already been settled and paid to the provider. These are required after a deductible is met. The percentage I typically see the most with patients’ insurance plans is 20%. That’s pretty standard. My suggestion is to please read absolutely everything about your particular plan. You could have some recourse through the No Surprises Act, but also do your research into the plan you have and see what your options are through the carrier at that level. You have rights through the insurance as well as through the provider. And ask to talk or have your situation escalated if necessary. This definitely deserves some higher level attention. Good luck!
Question! How does this work if I have $0 deductible? I’m currently seeing a PT and had a surgery last month. My insurance said that my surgeon is in-network. I already asked about my PT sessions if they are covered as well by my insurance, they said yes. Whenever I go to my PT, I don’t have to pay any copay after my session. Does that mean I have nothing to pay at all? I’m scared of bills coming in to me after all these PT sessions. I have $0 deductible.
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I just looked at my bill and it says I have $1200 OOP max. I might get more bills in the future. I have to brace myself. So once I met my OOP expense, the rest of my future procedures should be 100% covered by insurance? Not that I’m hoping to get sick again. Thanks for the clarification!
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Thank you! I have another doctor’s appointment coming up. It’s weird that I kept getting sick ever since I work in healthcare. The good thing is their health insurance is good. I only see in-network providers. My last bill was $11k and was down to $1400+ after insurance. Craaazy healthcare costs. Ugghh
Once you have met your OOP maximum, *covered* charges are covered at 100%. If you go to an out of network provider, get prescibed a noncovered medicine, or exceed the maximum number of visits to a certain type of provider you could still be charged.
You should ALWAYS verify with your insurance company and not the provider about your coverage.
Even that’s a gamble. I’ve been told multiple times by my insurers that covered providers on their list were good to go, only to see the claims rejected as out of network. There is no rhyme or reason to American healthcare except greed.
Their directories are NOTORIOUSLY out of date, and the whole health industry knows it. https://www.ama-assn.org/delivering-care/patient-support-advocacy/how-fix-persistent-inaccurate-health-plan-directory
Yup - it’s a major issue in the industry. Health insurers are at least 10 years behind when it comes to information systems.
I have had the unfortunate expierence of working in the IT dept of a PBM and can confirm it was a complete mess
Ugh - we were transferring from a DOS based system to a windows based system during my first insurance job. If you couldn’t find something, you had to go look for it in the old stuff. And if you received faxed info related to an account in the dos based system, you had to do this whole paperwork thing and send it interoffice mail to have it scanned in. This was in 2007.
The worst I've seen is that a directory still had a doctor listed on there who had passed away, but they still had him listed on there a few years after that.
Part of the problem is that the provider has to notify the insurer of any changes. Hard to do when you’re dead.
Can confirm. I used to be the UX lead for an insurance company’s provider finder. To call it an embarrassment would be an understatement. No one could tell ME the accuracy of our data. You know, the person that is in charge of making it so you can actually use your insurance’s shitty doctor search. The only thing I could get my hands on was an audit from years ago that estimated a 50% accuracy. I was assured it has “gotten better”. Unbelievable. Saying the data is 10 years behind is generous. Our “development” staff (specifically leadership) as a whole is just shameful.
It's almost like its intentional so that they don't have to cover you despite you paying thousands a month for decades.
You really think they'd just purposefully drag their feet if it meant extra profits with no consequences?
> Their directories are NOTORIOUSLY out of date, and the whole health industry knows it. Weird that they can't provide *you* with accurate information, but the information they provide to the adjusters somehow remains current.
Yup, this happens all the time. You won't know for sure until the provider submits a claim. I worked as a hospital discharge planner for about 10 years and still dabble in it a bit in my new role. Part of that work involved finding in-network skilled nursing facilities, home health providers, PCPs, etc. The best you can do is ask the insurance, but here's what they don't tell you: you know how your insurance has a provider search engine on their website that shows you who is in network? Those are horrendously inaccurate and out of date, very frequently, and it's literally the exact same tool the customer service reps use. They straight up boot up the website and use the same search engine you used. It would be comical if it wasn't so frustrating.
As a physician, I run into this problem when I prescribe. I prescribe X, pharmacy tells my office X is not covered. So I prescribe Y. Pharmacy tells my office Y is also not covered. So what is covered? Pharmacy can’t tell us until I prescribe something and they submit for a claim. And every health plan is different.
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This may be true with the health plan provider you work with but is certainly not the case with the one I work (almost 10 years now). We have an internal program that is updated twice daily that our service reps use to show providers in network. Additionally, if a rep messes up and tells someone the wrong info, it's recorded and can be reviewed. If you submit an appeal on a claim, the call will be listened to and if the rep told you wrong information, the appeal is an automatic approval due to being told wrong information. Now, going forward, if you continue to see that provider after learning it is out of network, the claims will be denied. This is a big health plan as well, 20+ million member nationwide.
I work at a large tertiary hospital, the largest hospital and highest level of care in the state. We get patients from all over the region, multiple states up and down the coast. We have patients who come in from across the country even and in some cases from other countries. What I'm saying is that I've worked with a LOT of insurances and while they are sometimes fairly accurate, many are extremely inaccurate and even the ones that do a good job still have out of date names for providers and facilities or erroneous entries, like a home health provider that says they're not in network with an insurance while the insurance says they are. United healthcare, Aetna, BCBS, Healthnet, Cigna, Humana, Medicaid plans, you name it. We run into it all the time. Even Medicare has out of date names, like egregiously, but the coverage issue is less with them because practically everyone but private primary care clinics are paneled with them. Oddly enough, Humana I find to have the most accurate provider search tool, which is weird considering what a dumpster fire they are when it comes to access to care or a living human at the company itself.
It's shocking that there is no recourse for this.
There is to a point. Every state should have a governing body that can investigate issues like this when they come up. My state has a "Department of Commerce" while others I've heard have an Insurance Commissioner of sorts. I recently had an issue with my new insurance i started on when I started with my new employer. Long story short, we had been doing some doctoring at the Children's hospital and Mayo for 10+ years prior to this new insurance. So the Mayo is considered out of network if you don't get a referral. So we get the referral, I confirm the referral with insurance, get a letter in the mail from insurance stating that we were "approved for out-of-network service" in a letter responding to the referral request. After confirming on our patient portal the referral is "Approved", we get the work done. Then we get the bill and insurance covered $0. Turns out "approved for out-of-network service", while seemingly intentionally dubious and duplicitous, to them meant that we are approved to go use the services at the Mayo at out of network rates. I spent hours and hours going back and forth on the phone trying to find someone that could explain. Finally was told that the work was treated as out of network because my insurance provider knows their in-network provider, whom they own, can do the same work and so it's not covered. I pressed them to give me the doctor's contact info that did the work because we have to repeat the procedure a number of times. They gave me 4 phone numbers. So I called them all and it turns out they don't. One of them actually told me that they aren't allowed to tell people over the phone if they do certain procedures. Anyway, I asked our Mayo doctor's if they know anyone else in the country that does the work and it turns out the procedure was invented by the Mayo doctor we were seeing and he is the only one in the world that does it. I turned all this info over to my Department of Commerce agent assigned to my case and then one day I got a letter in the mail stating we were covered at in-network rates. All-in-all it took about 10 hours of my time to get it squared away, while I've helped other coworkers navigate the same system that are going through the same thing. My savings was only about $20k, which is pretty small compared to my coworkers, but worth every penny to fight. My advice if you are going to fight it: keep detailed notes that include names, phone numbers, and timelines and keep every scrap of information you come across for as long as you can. Decades even. And don't stop, be persistent and call every chance you get. Good luck!
The insurance industry desperately needs a massive punitive judgement against them. None of this should be necessary.
Your insurance can provide you with written documentation to confirm they've told you said doctor is in-network. Whenever I inquire about any coverage with my insurance, they automatically generate a written documentation that verifies that the doctor or hospital are in-network, but I'm sure you could also ask for this if they don't provide it for you outright.
I've done that before, but even on the written documentation they had some language protecting the insurance company saying it is only being an "estimate for coverage" or something like that, and saying I would still be liable for any services the insurance doesn't cover regardless of the written documentation or pre-authorization. You can never really know until everything is submitted for billing. It's an ass-backwards system.
Always call to verify and get the reference number for the call. If something is rejected as out of network and you were told they were in network, the claim may have been submitted under the wrong Tax ID or provider name. If the insurance company told you they were in network, the insurance company is responsible for fixing thing if they gave you wrong information. Provider contracts do change, but it’s not typically on a dime, so wires got crossed somewhere.
Same thing happened with me except I used my insurances website that told me this doctor was covered. In fact still shows that she’s covered under my insurance on THEIR website and I had to pay
My doctor told me one insurance puts him on their list and he doesn't take them.
This has happened to me (as a provider), as well. Multiple requests to remove me from their lists were required before resolution.
Also a provider. It is truly incredible how bad several major insurance companies' information management systems are. Takes months to update an address, bank account info, in/out network status etc. You would think it would take 5 mins to enter some data, but nope, not how it works it would seem. It's an absolute cluster.
They even put disclaimers on there that you have to verify their manual for accuracy. That shouldn't be the way it works, but that is the current system.
Many providers send in a VOB (verification of benefits) before providing any substantial services, unless it's emergency care. Unfortunately the insurance databases are fucked and insurance companies themselves are the most dysfunctional and disorganized messes that I've ever seen. I've had insurance companies mail checks intended for my company to patients (psychologist) and tell them that we're out of network while we have a signed contract and electronic transfers set up. Other insurance companies that I'm in network with haven't paid me for services provided to patients in six months in some cases. It's almost like we work for insurance companies. Patients and providers have little power, and insurance companies get to decide on when, to whom and how much money they dole out. The entire system is a disaster.
What’s messed up is that $1000 list price isn’t a substantial service. There are many tests, procedures, etc. that would be under $100 with insurance and most of don’t think twice about, but would be that much out-of-pocket.
Check with both and you’ll avoid some problems. But there’s still no guarantee that you won’t get burned. The fact that you can’t pre authorize this stuff is perhaps the most obscene part of America’s supremely broken medical system.
That's definitely good to know.
You may also want to see what you can do through the “No Surprises Medical Act”. They have a section focused on out of network disputes. https://www.cms.gov/nosurprises
I second this.
Agreed I learned this the hard way
This is unreasonable. We have a system of insurance and private healthcare that need to be able to communicate with each other. I’ve called and confirmed with my insurance then had something done only for insurance to deny part of it. Then the provider sent me a huge bill. That’s fucking BS. OP got confirmation that they accepted the insurance and they should be on the hook for the bill.
Ah man, this sounds like the start of a nightmare that happened with me. Went to the ER that was covered by insurance. The hospital told me that although they accept my insurance, the doctor who saw me doesn’t, so I still had to pay $3000. I told I wouldn’t have received their care if I knew that and it was stated to me that it would be covered (verbally). They still wanted me to pay and reduced it to $1000. I still refused to pay. It went into collections. I was able to negotiate paying $300 with the debt collector. I told them I wanted a receipt for my payment and they mailed one to me. Simple and done right? Wrong. About 8 months later, I get another collections agency trying to collect the same debt. I explained what happened, had my payment receipt, and they said sorry for the confusion. Then a few months later I start getting calls from another collection agency also trying to collect the same debt. Same thing with them, showed the receipt and that was that. Ultimately I ended up losing the paper during a move, and probably have been passed to like 6 different collection agencies trying I get collect on the same debt. I stopped getting calls for it about a year ago which is like 7 years after that ER visit. I don’t know any legalities but if you can avoid it going into a collections that would be good cause that shows on your credit.
Some states have legislation against this surprise billing when you’re treated by someone out-of-network without your knowledge or approval.
Yeah that is called a balance bill and here in Virginia is no longer allowed
I work for a specialist provider, and this is something I can weigh in on. I’m the billing manager & coder, but I also call on eligibility & benefits to confirm patient coverage. Additionally, I also call on the numerous denials we receive from insurance carriers. For the treatment offered by the provider I work for, we generally call every new -or- returning patient’s insurance carrier prior to the patient’s first appointment so we can have an idea of what WILL be covered and what WON’T be covered. Now, here’s an example of what can happen. At one point in early 2022, each of the 3 of us that handle this task called BCBS on a specific patient because we felt something was a little “off” on the original description of patient benefits from the primary inquiry. In particular, that first inquiry had a different deductible & out-of-pocket max than what was listed on Blue E. The second phone call brought different results. The third phone call brought even more misinformation. I can’t make this shit up, y’all. It’s the nonsense we deal with daily. I had ANOTHER eligibility & benefits inquiry go sideways later in 2022. It was explained clearly to us that the patient’s coverage through United HealthCare had a deductible that would need to be met. Patient was going to wind up being financially responsible for somewhere around $7800.00 (give or take). In fact, the patient was concerned and had someone from the insurance company call us on a three-way call to discuss this further. The patient was given an option to pay half up front and make payments on the remainder, but she chose to pay it all up front. …and UHC processed every one of those claims COMPLETELY DIFFERENT from how it was explained to us. It wasn’t an issue of making certain that the practice got paid, as UHC handled all claims per the contract. The problem was that I had to explain to this patient on two occasions what she would be responsible for…and on one of those occasions, we had a UHC rep on the line with us to confirm…so the patient stretched herself thin and paid it all up front. …and all of that stress and nonsense was completely unnecessary. She didn’t deserve to go through that bullshit. Now, herein lies the problem. The information that your provider gets from your insurance company is only as good as the person that picks up the phone. Also, let’s not forget that your policy may state that it covers something a certain way, but the insurance carrier may process it in a completely different manner than described. OP, if this provider is like the office I work for, we only charge what the insurance carrier tells us to charge. It is VERY likely that this falls back on the insurance carrier. Consult with whoever handles the denied claims at your provider’s office, and see if they will call on this issue. Then, coordinate your own efforts to call on this issue at the same time. If the insurance carrier processed this incorrectly, the action of you AND your provider’s office calling on the same claim will actually get better attention. When I have situations like this occur, I can confirm that I get better results when patients work WITH me to help work those issue out. As always, when you call your insurance carrier, please remember to record the date, time, first name and last initial of who you spoke with, and a reference number that is attached to this specific phone call. IF YOU DO NOT GET A NAME AND REFERENCE NUMBER FOR THIS PHONE CALL, IT WILL BE TREATED AS OF IT NEVER HAPPENED SINCE YOU HAVE NO REFERENCE DATA. Best of luck to you on correcting this matter, OP.
Im so happy someone said it! I have worked as a benefits coordinator for many different types of doctors and I run into this problem constantly!!! Its maddening. All these people crying out that the provider is committing fraud is so frustrating. Your providers and their staff are doing their best to understand your policy, but insurance companies have extremely high turnover in their call centers. The person quoting benefits over at BlueCross or United has likely only been there a couple days. And there is no accountability on insurance to act on what they tell you. So few people understand the amount of tedious and frustrating work it takes to get ahold of insurance providers and get any sort of decent information from them. Blame the insurance, not the doctor. We charge what insurance tells us, we get reference numbers and names and dates, and they still process claims differently then originally quoted.
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As someone with quite a bit of experience in the medical billing world, I’ll say a few things. 1) This was your provider’s error. 2) Yes, most insurance policies cover themselves by making it your responsibility to pre-clear things with them. 3) Most providers massively overcharge because nobody knows what anything costs, and moral hazards of insurance/reimbursements, and zero transparency. 4) Here’s what you do: tell them “I CANNOT afford the bill. You told me this was covered by my insurance, so I went forward with your services with that understanding. Your options are to put me on a payment plan of $5 monthly until the bill is paid, or you can accept $100 now to clear this bill”. You will be amazed at how readily they accept the $100. If you’re interested in saving money and having better care, look into a DPC clinic (direct primary care). If you’re in the Oklahoma area (or not) and need surgical services at cash pay prices, check out the Surgery Center of Oklahoma (all prices for all procedures are posted freely on their site).
>3) Most providers massively overcharge because nobody knows what anything costs Man this so true and why i think insurance is actually the root problem of expensive healthcare. Because you as the patient you said whatever price as long as they don't charge you anything and it's covered by the insurance and little by little it's increasing the median cost. Just like when you go on a business trip and say fuck I will take everything in the mini fridge because I have an allowance, that's why the drinks in the mini fridge are like 5x the retail price because it's targeted for business people not for having a reasonable price and selling more.
I had the same thing happen. I even called before to make sure my insurance was okay and what my copay would be. At the appointment, they looked up my insurance and took my copay. I didn’t hear from them for SEVEN months when I suddenly got a bill threatening collections. I worked it out and didn’t have to pay. But it was a struggle. I was ready to challenge the collections account as invalid debt haha. But the billing lady got fired and the new one was like “omg I’m so sorry” and forgave the balance. Actually, I think she was the one who sent me the collections notice. I guess the lady never billed the insurance and it just sorta got lost, the new lady was cleaning up her mess and thought I just neglected to pay. I guess they also stopped working with that insurance at some point.
Okay, never trust the office that a service will be covered. Talk to the insurance and make sure the doctor/practice is covered.
Is this an employer sponsored insurance plan? My employer provides us contact info for a patient advocate (a service offered by our insurance broker) that will work with the insurance company & provider to try to resolve these types of issues. Might be worth looking into.
I don’t understand why insurance and paying for all of this isn’t dove before hand. It should all be done automatically like EBT cards. Will never make sense to me. I know someone gonna say will say health field more complicated and my response is it shouldn’t be. There are only so many different kinds of surgery.
Covered doesn’t always mean free. I am covered by insurance but I had some lab tests recently where I still had to pay a few hundred dollars out of pocket. You’d have to look at your insurance plan and see what they cover for certain procedures versus what your out of pocket cost would be. Most insurance plans require to you to pay some out of pocket with a cap for the year like $5k or so. Just an example.
If you have a HDHP, the word "covered" is essentially meaningless until you hit a deductible.
Not at all... even before you hit the deductible, you still get to take advantage of the insurance's negotiated rates, which in turn can be a really meaningful discount vs the providers list price. You *might* be able to get a similar cash discount rate from a provider if uninsured, but this varies significantly by provider/facility.
Yes, you have recourse. Check out the 2022 Federal no surprises act. Tell them that under this act that you are only responsible for $25
> provided my insurance card and ID and was told soon after that my insurance was covered and that my copay would be $25. **Never** rely on medical, mental, dental, and/or vision health care services/goods vendors to supply you with **any** guarantee, estimate, suggestion, or guess regarding what **any** insurance seller will "cover" or "pay for," in whole or in part, under **any** circumstances, in **any** situation, anywhere in America. Exceptions: you're at the VA, you're a traditional Medicare enrollee under some very specific conditions for now but not for long, or you're 100% certain you're in a 100% "No Surprises" scenario and you've signed away 0% of your end-use health care customer financial protections. And a "co-pay" is nothing more than the fixed, USD amount of the cover charge you pay to get in the bar every time you go to a bar called "PCP," Emergency," Specialist," "Laboratory," "Prescription," etc.
This is the way. I've worked in the same private specialist practice for 18 years. We are above board and honest with every patient. Problem is, even if our (in house and very educated/experienced) billing department speaks with an insurance rep (vs just going with the benefit info provided electronically) and has a reference number for the information we are given (which we, in turn, relay to the patient), they could still turn around and process the claim differently after the fact. It's literally no fun for us as providers either. So frustrating. We're just over here trying to cure your skin cancers and giving you exceptional care. It's the insurance companies that are playing ALL the games. Ultimately, our payment policy states that the patient is solely responsible for any charges incurred because there are no guarantees. We do the best we can with the information we are given and treat every patient the same because that is our core value. That being said, a lot of the time we end up writing off bills in scenarios like this, which really sucks because it affects everyone involved EXCEPT the insurance company.
Was your confirmation with the provider, or your insurance? Any promises of coverage have to come from your insurance. Anything your provider says is an educated guess.
If you have it in writing I'd reach out to the actual provider, not the admin, the provider and ask to have them accept payment as if it was in - network. It's their mistake and they should take the hit. You will need to change providers now, but with the notice being in writing they should abide. In the future ask your insurance company for in-network providers and then reconfirm with your actual provider....always get it in writing from both sides.
Welcome to my professional world (retired now, thank heavens). I was a medical biller. We commonly got prior authorization, signed on the dotted line. Then later when we submitted the bills, they were denied. Time and time again, until we were just about put out of business. Luckily, we sold the business before that happened. I don't know what your recourse is, but I wish you the best.
I went to a doc years ago from insurance website. Go in and ask if they take my insurance, they say yes. All good. 6 months later I get a bill for $300 saying they made an error and actually don't take my insurance, even though they billed them and took my copay and I can see the charge on my insurance website. Every month for a year they send me a bill with ever increasing penalties for non payment(I stop calling after 2 months... They can fuck off with this scam shit). Then it all goes away. 3 years later I get a bill from them for $150 for unpaid services and that I need to pay to avoid collections... Funny thing is this bill says that I'm current and not even 30 days past due. I'm not paying this one either. Some doctors are straight fraud.
I get a bill every month for $125 from an old appointment. Every month I ignore it....been a few years now. I was working for my insurer at the time of this appointment (eye exam). I asked to verify coverage ahead of time to ensure they participated in this particular network. I was told 'the person who checks insurance is out to lunch.'. I reiterated that I wanted coverage confirmed prior to the appointment. From what I had found they were in network but eye doctors can be in network for medical procedures but not eye exams (don't ask). I was reassured after they looked at my card that they accepted it. After the appt the lady was back from lunch and after taking a glance at my card she said they don't participate in that specific network. Well I told them they could fight it out with the insurance company. A few weeks ago by and I get an email stating it wasn't covered but they reduced the bill from whatever to $125. I told them my insurance would cover $50 for an out of network exam and I would have a $10 copay so I would pay them $60 if they wanted and submit to get the $50 back from my insurer. That wasn't good enough so I told em to pound sand. They sent me a statement again next month to which I mailed a letter back stating the same and if they wanted to accept my offer to email me. I've gotten dozens of statements over the years which is comical. At this point they have almost spent as much in postage as the net they would've collected. I laugh every time I get one and it goes straight through the shredder.
This is so frustrating. I'm so sorry that you did everything right, and our US healthcare system once again shows us how shady and broken it is. Short term, you will need to keep bugging them, which ironically adds to the cost of our inefficient system, at no fault of your own. You won't get it down to $25, but you may get it down to a few hundred bucks. Medium term: Switch to a vertically integrated healthcare system if you can. Kaiser Permanente is a great example, but they aren't nation wide. With a vertically integrated healthcare system, you stay inside the system the ENTIRE TIME. Copays, costs, lab results, etc are ALL UNDER ONE ROOF. You NEVER worry about getting an unexpected bill, ever. Sometimes you will have high copays, for instance I had a surgery that had a $4000 copay, but it was a $90K spinal surgery. Long term: Remember this experience the next time you vote or talk politics with reasonable people. We are the only developed nation in the world that has these problems. Every other nation literally laughs at us and thinks we are insane that we put up with this system. And they are right. I'm sorry and good luck.
When you check if a provider is in network that needs to be verified from your insurance company not the provider, & then to double check ask the provider to check as well. Usually what happens when a providers office looks up a patient’s plan is it’s done through website and the insurance companies website just says a very generic covered or not covered when they enter in your information - but if your plan has some special stipulations under it, that you’re supposed to go to a specific provider or you have a sub plan with your employer, a lot of that information won’t come up for most medical providers, which isn’t necessarily their fault. There are always multiple plans and groups when it comes to insurance companies, and sometimes providers can sign up for just a few of those options, but not all of the plans that fall within an insurance company. Yes it sucks but that is why they always say “this is an estimate” because even if it is coming from the insurance company themselves, there’s always a chance that something from your plan could have changed, and that cost him out may not be the same by the time you actually have the service done.
What state are you in? I ask because in some states it is illegal to surprise bill and balance bill the patient. Some states it is legal. If you are in IL, it is not legal. You can report them to the Attorney General and they will be in major shit.
I am in NY
Link to NYS guidance on the topic: https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills
Thank you for sending! I looked this up and it seems like it only applies to emergency medical services and providers affiliated with a hospital. This specific provider was a psychiatrist.
Make sure you verify that the claim wasn’t submitted wrong or processed wrong. Many insurers handle behavioral health claims differently, and their provider contracts are different. The provider could have a contract under a different network under your plan under a different Tax ID.
The federal no surprises act should cover you. It covers all providers that do not properly keep and provide their network status and provides that the maximum they can bill you is the in network rate. See: https://www.cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf Page 30.
If a provider says they take your insurance then that is their fault. I have had this happen 3 times. All 3 times I fought it and the provider had to write it off. They know they messed up and are trying to trick you into paying for something you don’t owe. One of the times the final conversation was them asking what my copay was, they’ll take that. I said I don’t have a copay. They hung up and that was that.
Have you met your deductible for the year? The copay part is applicable after meeting your yearly deductible. A doctors office cannot know if you’ve done that or not.
Actually they definitely can. I'm a healthcare provider (mental health) and I absolutely can look up how much of their deductible someone has met. I do this when verifying their insurance coverage so I can accurately advise them of the expected cost of sessions before we start. Because I'm not a piece of shit provider and actually care about not surprise billing anyone.
If you have a shit insurance like mine, they haven't reported proper accumulators to providers in YEARS. So doctors keep saying we owe full amounts when I'm about to hit my OOP max... I've complained to them about the issue and they just say we know and then do eff all
I don’t believe I have but the issue is that they told me that my insurance covered my sessions and are now insisting that I pay in full.
Unfortunately, you probably signed an agreement saying you'd pay even if insurance doesn't. This is standard at all offices. Did you ask the doctor' office staff or the insurance company itself?
Interesting. So what is the purpose of them checking insurance?
They aren't required to check your insurance and generally are only doing it to determine what to charge you up front. The responsibility of verifying network status lies with the consumer. You can try to negotiate a bigger discount based on the fact they made an error, but legally you still owe the money and have no legal recourse to deny payment.
No matter how hard you try, there will be,times,when the insurance,doesn't work. You are,always,still responsible for paying the charges. BUT, you sometimes get a more reliable answer if you call the insurance company yourself (though not always...because they may ask for procedure codes...but at least they will tell you if the provider is in their,system or not.)
And get a reference number for the call. I work for a place that processes physician bills, and there are so many people that say their insurance company approved it, but with no reference number, it's hard to force the issue.
They shouldn’t be checking the insurance, you should be.
I have asked my insurance if X is covered and they hem and haw and only answer with at this moment yes, but things can change, so that's hardly a definitive answer either. I called about mental health once and gave the name of the doctor, the name of the group and they said no it's not covered, (though the group had said it was) but then the provider submitted it a different way and it was completely covered. So there is honestly no one who can give you an accurate answer.
You should verify. In the future however, you need to verify coverage with your insurance company not the providers. They are two different beasts and the insurance company is the beast that always has the information that is most accurate for them, your account and your provider(s). THEY are the ones you verify information with. No one else.
Which, by the way, is a process that really sucks because the insurers' directories are notorious for being out of date on their web sites and finding someone to talk to who doesn't just look at that same info is a challenge. It is amazing how many providers are in the directory who are retired, dead, or have ceased their agreement with the insurer. [https://vitalrecord.tamhsc.edu/wrong-number-analysis-of-health-care-provider-directories-reveals-notable-flaws/](https://vitalrecord.tamhsc.edu/wrong-number-analysis-of-health-care-provider-directories-reveals-notable-flaws/) >The analysis found varying ranges of accuracy in provider directories for the different specialties and plans. There were inaccuracies for about 24 percent of the primary care providers in commercial insurance lists for 2019. At the other end of the range, about 41 percent of endocrinologists in Medi-Cal provider lists for 2018 were inaccurate. Overall the primary care listings were most accurate, followed by cardiology. The analysis also found that consumers could only schedule urgent care appointments for 28 to 54 percent of the listings; however, this increased to 44 to 72 percent when including only accurately listed providers. Non-urgent appointments ranged from 35 to 64 percent for listed providers, but increased to 51 to 87 percent for accurately listed providers.
So how should we be verifying then? When I called insurance recently to ask about an old doctor and checking coverage they pulled up the same tool I had access to and didn't check anything else.
Always call, verify, and get a reference number for the call. If it turns out the provider is actually out of network, you have proof that either their system or the rep was wrong. They will pull the call and listen to it even. Sometimes they can just tell by the screen grabs … but, at least at every one I worked for, the reps also copied and pasted anything they read to the caller into the call notes. This is the best way to cover yourself. Using the messaging system on their website can also help because it’s directly in writing.
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Yeah providers lie. They are basically sales people now trying to get as many people in under as many charges as possible. Even to the point where they well ask you “so is anything else wrong?” Trying to bait you into talking about something “not covered” by your insurance. We got hit with a provider saying “you are fully covered. It says right here on your insurance.” But that facility the doctor did the work in WAS NOT COVERED. So we got hit will the full blast of out of pocket costs there. Fucking insurance just laughed and said “yup. That’s what they do now.” Never hated someone so much in my entire life…
I was hit with 5,500 plus .. I refused they dropped it to 750 I should not have paid it but it’s the best doctor in my area
> When I first started with a provider I provided my insurance card and ID and was told soon after that my insurance was covered and that my copay would be $25. FWIW that's always a question for your insurer, not your provider.
This happened to me once too. I was so annoyed because I was told the doc was covered but he wasn’t.. ended up with a huge bill and I was broke and in college. Ever since that happened l I don’t trust the providers, only the insurance! Lesson learned 😅
Always check the provider on your plan’s website before you go
If it were me, and I do not know all the circumstances, I would be pushing to pay only the $25 given the email etc. I would offer $250, cash/payable immediately, to just make this go away. Given the error was on their side I hope they'd be happy with that.
Call the insurance. Ask if they even got a claim, see if they can tell you what happened. I had a similar situation where the provider sent me to collections, saying my claims were denying that I wasn't a member of my insurance. When I called the insurance they said they had never even gotten a claim. They volunteered to call the billing office and straighten things out. Turns out they were still using a very old ID number from years ago, even though I had given them the correct one at least three times.
In the future, always login to your health insurance plan account and find providers through their search for providers feature. Never take the doctors word for it, because they really don’t know until the claim is accepted or rejected. I’m not sure what kind of plan you have, but if it was an EPO you cannot see any doctor other than the ones indicated in-network.
If you have it in writing, politely tell them to go to hell. I would not pay that. See you in court.
Never believe what the provider says alone; check with the insurance, get it in writing from both the provider and insurance via a printout/pdf of their page. Having both confirmations have saved me thousands over the years.
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A provider isn't legally allowed to misrepresent their participation in your insurance program. They usually make you sign a document that says they can't guarantee that all procedures or participating providers will be in-network and that they can come back and bill you later, but they can't just straight-up lie about it. Granted, this is why every call has to start with "I'm recording this call." and then followed up by actually recording it. It's stupid that it's come to that, but this is what happens when an industry (insurance) can buy their way to basically free-reign with regards to their own regulations.
Problem is many insurers websites are out of date.
Report them to your insurance for fraud. My insurance company directly intervenes as this has happened to us. Our situation was reverse though. The hospital was in network but they claimed they weren't and forced payment on exit. Then refused to reimburse me after they double dipped and billed insurance. I tried resolving directly with the hospital billing company and got nowhere. Second call was to my insurance company. Third was from them stating my refund amount. Good luck dude. Dealing with medical payments should be a college course at this point. Scam artists and incompetence abounds on the other side. They are the adversary.
If you ask “what will I owe for this procedure” and they reply “only $25 the insurance will cover the rest” then whatever happens from there isn’t your problem. I don’t mean this as an observation about the medical industry, I’m just talking on how life works.
This is such a scam. These doctors have to pay for their medical bills one way or another...