Question About Out-of-Network Insurance Claims

I do medical billing for a doctors office - I feel your pain. Dealing with insurance companies is no fun - you end up talking to 5 different people that tell you 5 different things, and none of them make any sense half the time! You can ask your insurance company if there is an appeals department. Most companies have these, and you can write a letter stating your case and that you were not informed the doctor was out of network. I had to write one of these for an ER visit my insurance co said was not "emergent" enough to warrant me taking my child to the ER. I wrote a letter of appeal, and included a letter from my primary doctor stating that she instructed me to take my son to the ER, and it ended up getting paid for. I am not saying this will guarantee they pick up the bill, but it's worth a try. This is fairly common, though. A lot of anesthesiologists are non-par with most insurance companies. This way they do not have to contract with the ins. company to accept a lower rate. Good luck!

I process medical claims for a living so after 20 yrs of working in the industry I've learned everything.

In most insurance the driving force behind a payment is the surgeon and the hospital. If those are both in net then everything else is in network (because you really don't have a choice on your anesthesiologist, pathologist, radiologist as these are provided by the hospital). With any insurance claim you have the right to appeal the processing. Gather your paperwork, and write a letter explaining that the surgeon and hospital were both in network so all billing pertaining to the surgery should be paid at a higher rate. Send in a copy of the out of network processed claims along with your letter, note the dates of your phone calls if you have them, and it should be taken care of. MAKE COPIES OF EVERYTHING before mailing. Also make sure your letter contains your group number and member id number at the top of each page.

If you find that you are not getting satisfaction from the insurance company file a grievance with the insurance commissioner in your state giving them copies of all paperwork and the outcome of your appeal. The Department of Insurance in your state will review everything and file paperwork asking for a review from the insurance company. The DOI appeals are taken very seriously by the insurance and will give you a correct outcome.

I had this same problem when I went into the hospital to have my first son. Dr was the only Anesethesiologist available that night and I wasnt told until I got the bill for $3800. I called and had the Dr office run the billing again and they got my bill down to $1800 but I had to live with it and just pay it off. I didnt have a choice and I dont think you will either. Set up a payment plan and move on.

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Unfortunately, you will rarely find an anesthesiologist that is in-network with any insurance plan. They just won't contract with us. For out of network benefits, your insurance plan will pay the usual and customary rates for your area for the service. You are responsible for your 20% and if the OON provider charges more than UCR then you can be billed for that difference also.

Added: I also wanted to add that most health insurers negotiate their hospital contracts with the professional services excluded. This means that we pay the hospital for their services but the different individuals who provided services while you were there are responsible for billing separately.

You should be able to contact your insurance company again and remind them that your in-network hospital is where the procedure was done and the claim should be be processed as in network. If that doesn't work, contact the hospital and talk to them. They may be able to have the enesthesiologist accept what the insurance paid.

yes, you can call your insurance company & see if there is a wrap provision on that policy where if you had the procedure done at an in-network facility they would process any out of network provider's claims at the in-network rate..since you do not have a choice of what anesthesiologist you choose or no way of knowing if they are in-network with your insurance. and the anesthesiologist office should have called your insurance & asked as well.

Call the office of the anesthesiologist. The last time this happened to me they adjust my bill way down. It's worth a try, good luck!