Do I need to pay this medical bill if I suppose to be 100% covered inside a network hospital?

Question

I rushed to emergency room and be admitted inpatient. My family called the insurance company and got approval right next morning. The hospital is inside network and service over there will be fully covered. Later on, I got bills from several doctors which asked me to pay for 50% of the charges. Some even ask for more than half because the excess amount that the insurance company think is over charge and don't pay is added to my bill. They say the doctors are outside of network that makes me responsible for 50% co-payment. My question is: If the hospital is inside network, the doctors that send by the hospital is not count as inside network? Or a serious sick people need to check each doctors' status before he/she receive any needed medical treatment?

Answer 1

Call the insurance company and reference the doctor's bill. You can also call the # on the bill and tell them your story. Something does not make sense.

ETA: There are doctors at the hospital who are in-network and who do accept your insurance. I am simply saying something does not make sense b/c your story states that you went to a hospital that was in-network. Usually this means the doctors who are working there are also in-network. Eg, I have only gone to hospitals that were in-network whose doctors were also in-network. Just check again with the insurance provider and the doctors on your billing form to determine if they were in-network or not. You may also want to discuss this with the hospital billing to determine that you were informed of this. Usually there is information on the admission that talks about who the doctors are and what their fees are.

Answer 2

These are problems that, under common sense, should be fixed by the hospital.  The sane thing to do would be that all the doctors that are practicing there be required to take the same insurances as the hospital, or for all of them to come to a consensus. That said, this is one of the nightmares of medical billing for patients. Sometimes it is just what happens, and you are stuck with the bill. Sometimes it is a mistake, or problem with the insurance or hospital.

Doctors that are at the hospital don't always work for the hospital, but they have privileges there, and can use the hospital for procedures for their patients. Usually they need to be available for call sometimes to get these privileges.

Some doctors, like anesthesiologists, might be available for several different hospitals, but are still considered their own practice. It would seem logical that these people are part of the hospital because of their specialty, but they are not.

If a procedure is planned, the doctor who is performing the procedure is responsible for making sure everyone is in network. (Your orthopaedist wants to do knee surgery, her office sets it up) The hospital is just a facility they use that has stuff available to the doctors, kind of like a gathering place. The hospital is not actually the provider. This takes people a while to sink in, we are not used to thinking about hospitals like that.

Now in the ER they have only the people on call to use or who ever happens to be there they can get. So, even though they might not be in network, getting the medical service to you is the most important thing.

Being inpatient, if the doctor has a concern, and there is a specialist hanging around they may ask him to consult. The specialist may be there checking on his own patients. It's possible the doctor recommends something, comes back to check once a day, and now you have several days worth of charges.

That said, you can sometimes get this worked out. Talk to the insurance company and ask them about it. Tell them you went to an in network hospital, as you were supposed to do. Have them explain the intricacies of your plan and how it works with the hospitals. Make them review the claims and charges, just to verify everything.

Call the hospital, tell them they were in network, but the doctors they chose to work on you are sending you bills that make it look like they chose out of network doctors for you. Ask them if there was a mistake. If they say no, ask them why out of network doctors were chosen when they had your insurance.

Then call the doctor's offices. Explain the same thing to them. You went into a network hospital, and don't understand how they are not in network. You may want to go there or at least mail them a copy of your card.  

When the hospital put the insurance in their computers, there could have been a mistake. The wrong one could have been put in, then given to all the other doctor's offices. Take, or mail, a copy of your care to all of them to verify, enclose a copy of your bill.

If the hospital made a mistake they should be able to correct it, if not, call the insurance and tell them. They may be able to call the hospital and have it corrected. (Hospital might eat it, or ask doctors to)

It's possible there was a problem because the insurance wasn't called till the morning. Did you give them your card when you went in the ER? Usually the people there call the insurance before you get seen, so it made me wonder.

When you talk to any of them, try to be calm, be as explicit as possible (have all your paperwork in front of you) and as perseverant  as possible without being rude.

At worst, if you have to pay, the doctor's offices can work out payment plans with you. Some may even write some off. If it is a hardship, you can tell them, they may ask for income info but wind up writing all or some off.

Good luck.

Answer 3

Just because you go to an in-network hospital does not mean that all physicians are part of the network.  If the physicians that treat you are out of network then you will have to pay the out of network coinsurance.  However, you should check you policy to see if your plan offers a PARE benefit.  I have worked in health insurance for 15 years and most plans do offer this benefit. This means that any pathologist, anesthesiologist, radiologist and emergency physician will be paid at the in network level of benefit as long as the hospital is in network. The only problem with this benefit is that it does not include the doctors that treat you while you are inpatient.  These providers are billing for an inpatient hospital visit and if it not the ER visits than it would not fall under the PARE benefit.  What I would recommend before you pay anything is to appeal with your health insurance company. Simply write a letter and say that this was for an emergency situation and you had no choice at who treated you.   Many times an insurance company will reprocess the claims as in network due to an emergency situation.  It is worth trying.  You should contact the physicans that are billing you and let them know that you are appealing this and they can put your account on hold until the appeal is reviewed. You should receive a letter advising of the outcome of the appeal usually within 30 or 60 days at the most.

Answer 4

I think someone made a mistake. If you are covered like you say. Why do you have to pay the doctor's. They should have told you that when your family called them. You know I don't think that I would pay that bill. But also I would call the Insurance company and find out what is going on. And also you said over there, Where is over there. What state were you in maybe that is what the the doctor's change where you were.  Maybe the doctor's change a fee. Call the hospital  and talk to medicine billing. Don't pay it until you have the right understanding. Good luck

Answer 5

Unfortunately, when you're in the ER or inpatient at the hospital, you can't always assume that every specialist who happens to be on-call is contracted with your plan.

Yes, there are certain hospital-based physician specialties that your insurer should pay the same money to as they would pay a network doctor.  (Note - that doesn't include all specialists, just certain "hospital based physicians.")  However, if that doctor isn't contracted with your insurance company, he can still bill you for the difference between that and his billed charge.  

Your best bet is to negotiate with the physician's offices.

Answer 6

If you were in the ER you will have charges from the ER physician and any doctor that visited you in the hospital that day. Just because the hospital is in network, doesn't mean the doctors will be. I know it's frustrating because you really have no say about who will see you, but unfortunately..it's true. It's your responsibility to make sure your providers are ppo.

Some plans have the following as part of their plan language..check yours:

We now pay providers (including non-PPO providers) who render care in a PPO hospital at the PPO level of benefits,

when treatment is provided due to an accidental injury or medical emergency. This includes the emergency room

physician, radiologist, anesthesiologist and pathologist.

If this is in your policy language, then yes they should price innetwork

Answer 7

You are responsible to pay the doctors' bills.  The doctors that work at the hospital who billed you are not staff doctors.  They are doctors in private practice who were on call during the time you were there and who are not contracted providers with your insurance company.  It is standard practice for out-of-network doctors to bill the patient the amount above what the insurance company paid them.  If you want to dispute the bills, call the numbers on the invoices and ask them to waive their fees.  Be very polite and calm when you explain your situation.  If they will not waive their fees entirely, ask them to lower the amount you have to pay.  I think you'll find them more than willing to work with you.