Doctor's office fraudulently misrepresented themselves as "in-network" What can I do?

Question

I had surgery 7 months ago. I have a PPO insurance plan that covers surgical expenses and anesthesia at 100%, in-network.

Looking for a provider to perform my procedure, I made sure to ask if my insurance would cover the anesthesia too. The woman working the front desk and answering the phones of the facility I chose for my procedure assured me that my specific insurance would cover the anesthesiologist.

When I asked the name of the anesthesiologist, I was told that they would have no way of knowing who would be on duty the day of my procedure and did not give out the names of staff.

Well, 7 months later I open my mail to receive a bill from the doctors office for thousands of dollars for anesthesia. When I contacted my insurance company, they told me the claim was rejected as the anesthesiologist was not "in-network".

I did the best I could to check with the provider's office beforehand and was assured that my insurance would cover everything.

What can I do to resolve this?

Answer 1

If your hospital is in network, the staff anesthesiologist needs to be paid as in network, as well.  

You need to call your insurer, and have them pay the anesthesiologist.

Answer 2

I work for a large insurance company and even with an out of network anesthesiologist we would pay that claim at the allowed amount. That means we would have paid it at the amount we would have paid an in-network provider. You would still be responsible for any difference in cost between the actual charge and the allowed amount. (This is called "hold harmless applies".)

Did the insurance company say the flat out rejected the claim or just process it is with "hold harmless applies" guidelines?

Either way due to DOL/ERISA legislation you probably have the right to file an appeal to your insurance company.  These instructions should be on your Explanation of Benefits or in your benefit book, if you can't find this call your insurer to find out about your DOL/ERISA appeal rights.

Answer 3

ask the insurance company to reconsider.  if the surgery was preapproved they should pick up the charges.  if they refuse, go to your state insurance board and file a formal written complaint.  i bet they cover it then.

Answer 4

you should have checked with the insurance company or checked their list of doctors and made sure only one of those was used

Answer 5

I've viewed your other questions regarding this subject (and also replied to some of them).  Just so you know, each question is worded differently and might be missing some details that's contained in your other questions...this could reduce the quality of answers you receive, since only the answerers who have read each question will know all the information.

I recall you mentioned that the anesthesiologist may not have sent the claim within your insurance company's filing limits.  Did you ask about this and find it to be true?

As you might recall from some of the other answers you received...

An anesthesiologist at an "in-network" hospital or surgical center should be reimbursed according to "in-network" provisions.

If that anesthesiologist is on staff with the hospital or surgical center, you shouldn't have a problem.  If that anesthesiologist is independent but still has their own direct contract with your insurance company, then you shouldn't have a problem.

The problems come in if the anesthesiologist is an independent contractor and does *not* have a contractual agreement with your insurance company.

In a non-contracting situation, your insurance company should still pay the anesthesiologist the same way they would pay an "in-network" provider.

HOWEVER...any doctor who does not have a signed contract with your insurance company can "balance bill" you.  (Bill you for the difference between the insurer's payment and the full amount of the provider's bill.)

Also, any doctor who does not have a signed contract with your insurance company can bill you if your insurer won't accept the claim after 6 months.  (It has generally been the standard to allow a 12 month filing limit for medical claims.  However, some insurers are negotiating 6 month filing limits into their contracts with medical providers.  If your anesthesiologist doesn't have a contract with your insurer, they never agreed to this filing limit and therefore can seek reimbursement from you if the insurer doesn't pay.)

Question...did your insurer pay anything at all towards the anesthesiology claim?  Or are you just being "balance billed"?

If you're being balance billed...not much you can do about it.

If your insurer didn't pay anything and rejected the claim for timely filing, you may be able to file an appeal with the insurance company and request that they pay the network rate for the claim.  Its *possible* that they will consider doing that, since it has only been 7 months since your surgery.  (Not a guarantee though.)  Also...keep in mind that if your insurer does make a payment, you would still be liable for any "balance billed" amounts.  (The amount the insurer approves on the claim is almost certainly going to be less than the anesthesiologist's billed charges.)

Additionally, you may also want to notify the patient advocate/rep at the hospital about the problems you're having.  They may not be able to help reduce your bill, but its certainly important for the hospital to be aware if patients are having issues with anesthesiology billing for services done in their hospital.

Answer 6

Unfortunately, the word of front-desk medical personnel means nothing.  Their response was not "fraudulent."  But the fact is that you have no control over the anesthesiologist that the hospital uses even if the hospital inself is "in-network."

I would try disputing this to the insurance co. on that basis.  I've known it to work.