Clinic verified BS in network, but Ins said out of network

mairew · March 2016

Ugh. I was dx at a NCI designated cancer center - a university teaching hospital in November. I was referred to their surgical oncology department and assigned a BS. The clinic phoned me prior to my initial consult and told me they had verified my INS and all was in order, that I was subject to zero deductible, 20% coinsurance, giving me estimate amount etc. which is all inline with being in network. When I attended the consult they gave me written estimation of the charges, again showing my share was 20% etc. Scheduled for surgery a few weeks later, the hospital admitting staff gives me the estimate which included all the fees (hospital, anesthesiologist and surgeon) at my 20% coinsurance amount. Wait several weeks and the EOBs from the INS company starts arriving. My BS is not covered and I am subject to my out of network deductible and have to pay the consult fee and the surgery fee. I have called the clinic three times and no one calls me back. I called the INS co and they said its my fault for not checking with them. Every other BS in the clinic is in network. I am so pissed off. I am on the hook for the fees plus I don't get any benefit towards my out of pocket. Cancer sucks and dealing with all the billing really sucks. Do I have any recourse? INS co has not been helpful, and Clinic wont call back.

LisaAlissa · March 2016

Hi mairew,

I'm so sorry you're having to deal with this. I have some questions and some suggestions:

1. Do you have notes on who you talked to about billing matters? They may very well have notes on who they talked to at your insurance company when they "verified" your coverage. And do you still have those written estimates? (from the consult & at the time of admission?)

2. Assuming you still have the written estimates (or can get them), does it say that you "can't rely on them, but should check with your insurance company yourself?" If it doesn't say that, then you will want to keep saying that you "reasonably relied upon their verification of benefits, and their written estimates--and would have chosen different providers if they hadn't told you their services were in-network" as you talk with various people. The "reasonable reliance" and that you would have chosen different providers "but for their assurance that they had verified that they were in-network" are important thoughts. As in it is their fault if your insurance doesn't pay them on an in-network basis.

3. But whether or not you were permitted by their terms to rely upon the written estimates, you now need their help and guidance, since you want them to receive the benefit payments they told you were available. Do they suggest you call your insurance company? Do they know who they talked to when they verified the benefits? Did they record that call? They very well might have...

4. Who is it who is not calling you back? Presumably the billing office will want to talk to you...since they will want you to pay. If so, ask them for help talking with the insurance filing department--and possibly re-filing. You want to find the person who will help you strategize how to get them paid in-network benefits!

5. For example, there may be an "ombudsman" at your hospital/NCIC-designated cancer center. I'd call the main number and ask for help if no one will call you.

6. Sometimes it's a matter of the coding used when submitting the claim. I've been hearing that there are different codes they use when it is an out-of-network claim. So that sometimes it's merely a matter of refiling with the right coding. (Does anyone know if that's right?) Has anyone checked with the doc's office and the hospital/clinic to find out if they still think they are in-network?

7. Finally, Ask your insurance company to forward a copy of the out-of-network claims that were submitted. You want to know what was filed! Tell them that you were told that your claims had been verified by the service providers before the procedures as "in-network." Do they have notes on who called and what they were told? (They should...)

HTH,

LisaAlissa

mairew · March 2016

Hi LisaAlissa,

Thanks for your detailed response. I do have the written estimates from the Clinic and hospital. The clinic is supposed to have a financial counsellor, but I have called three times and they haven't ever returned my call. I have called billing customer service and they say I have to talk to the clinic people to find out what happened regarding the misinformation I received. So the clinic is the entity that has dropped the ball and is not communicating with me. I cant believe they are handling this issue with silence. Billing for the institution has gone to single bill once a month but I haven't gotten anything from them since December. So my anxiety level is pretty high anticipating the huge bills that are going to hit all at once.

Thank you for the specific wording to use. The wording on the "Estimation" is "We have determined your outpatient hospital benefits for ....fees associated with your visit today. An estimation of todays visit is provided below." And the sheet goes on to list my in-network deductible and coinsurance at 20% with max out of pocket amount. Another "Estimate Worksheet" also provided at the same time states "benefit information collected before this visit" along with the same in-network patient benefits. So I had no reason to believe that this BS was out of network.

If I don't hear back this week I am going to contact the surgeon directly, and also start writing letters to the clinic and hospital administration. But I shouldn't have to do this.

labelle · March 2016

Something similar happened to me. I was able to settle my out of network expenses at a discounted price, that is what the provider would normally get from the insurance company. This saved me thousands of dollars. I put my request in writing and used a template that (I think) I found on here-but it still pissed me off and cost more than an in network provider would. In my case, my insurance told me my chosen provider was in network. Turns out there are 2 breast centers in my area with similar names, one in network, the other was not. I still thought the provider should have caught this and someone ought to have said, "Hey, you know we aren't in your network and this is going to cost you a bundle" but that did not happen.

vlnrph · March 2016

Don't give up. Both the clinic & insurance company hope you will just quit fighting and pay them!

LisaAlissa's specific advice is priceless. Do take notes when you call, write down the names of "customer service" representatives, etc. Ask to speak with their supervisor if the person answering the phone can't help. Keep copies of all letters you send and consider requesting return receipt.

I have heard about coding errors preventing proper claim processing so double check that as far as you can. It is very annoying that a consumer should have to do a specialty task like this. Contacting the surgeon directly is a good idea. They generally want to take action whenever possible and can usually get things done...

mairew · March 2016

Hey again. You all brought me good luck for a change.

The Clinic finally called me back today and said the BS should be in network, and she will contact the Credentialing Dept and see what the problem is. Fingers crossed they can fix this and not leave me on the hook for their mistake. Thanks again for all your comments and help. I will update when I hear more.

BarredOwl · March 2016

I called my insurance company to ask if a particular physical therapist was in network and they told me "no". I called the facility, and they told me "yes" because the facility was in network. It turned out that the facility as a whole was indeed in network (and all its associated practitioners), and insurance paid the amount they were responsible for in full. I hope your situation is similar.

BarredOwl

Creativevintage · March 2016

Insurance companies are notorious for this. I work at the Mayo clinic and whenwe are contracted with a network, all of our physicians are in network yet I get calls almost daily from patients who say that the insurance company is telling them that one of our doctors is not in network. Push back hard with your insurance company as I am quite sure that it where the error lies. Clinics and hospitals send them monthly updated lists with all the doctors and their credentialing information. Also, when the precertification staff at the clinic called, they got what is called a voice certification number and you can call and ask them to provide you with that number. The Clinic can resubmit the claims and if they won't, you can appeal to the insurance company. Just make sure you write everything down and expect to have to repeat the whole scenario several times to your insurance company....

ChiSandy · March 2016

I have had the opposite experience, even before bc. I would go on my insurance co’s site and verify the provider and facility were both “in-network.” Then, one day, my PCP announced out of the blue she was no longer accepting that particular insurance (though the insurance co’s site still said she was in-network). Had to change PCPs--my current one’s great, a master diagnostician, very simpatico and was actually Bob’s Chief Resident at U of I when Bob was a resident. But my old one was marvelous too, and she’d been my primary since Gordy was four years old. Another time, I checked my insurer’s list of in-network labs, and chose the one in my PCP’s medical building. Well, in the interim they too had ditched that insurance. (Not a big deal because it was a small fee, but still maddening). And then, after my diagnosis, I checked with my insurer to confirm that compression garments were covered--they said yes, not even a co-pay. Well, the shop where I got mine would only take BCBS, not my insurer. Now, of course, I’m on Medicare--which will give me two free mastectomy bras per year and a free form every other year due to having had a “partial mastectomy” (even though my operated breast is now bigger, not smaller), but neither Medicare nor my BCBS will cover compression garments!

mairew · March 2016

Well the Clinic called me back and said the BS was not fully credentialled until Feb with my INS, and she is referring the matter to the Revenue Cycling Manager (what is that?) who apparently is her boss, to resolve, but of course the RCM is out of the office for several weeks. But she did say my account is on hold until they figure it out. Yikes.

Hopeful82014 · March 2016

In addition to the above pitfalls, I have found that some providers are listed as being in network - but ONLY when they are seeing patients at a specific site, say, at one of 3 clinics within their system. This is not noted on my insurer's website, of course. It makes it look, for example, as though one has tons of ROs nearby from which to choose when, in reality, it's half a dozen.

The moral of the story is call first. Take notes. Keep notes!

Beatmon · March 2016

My PS office and the surgery center BOTH said that they were in network for me and that all would be covered since I had already met my deductible. 6 months later I received a statement that the center was not in network and that I owed 30,000. After much discussion, it dropped to 13,000...to cover the cost of the implants. After I called my PS on her cell, she discussed the error with her staff and the owners of the surgery center....both were guilty of misinformation and the charges went away. I was so lucky that they owned up to their mistakes.

Geeper · March 2016

It sad but some insurance websites take a while to update their system. Always best to check with both your insurance company and your provider to verify in network status. Some providers have different tax id #'s or national provider id #'s that they bill under, so they may be in network under a different TID# or NPI# and not others. As a patient/member you think that your MD is taking care of everything behind the scenes, and then you get hit with a hefty bill. It's upsetting...

Always good to know your rights as a patient (ERISA), Grievance and Appeals process and to request a copy of the evidence of coverage from the employer and if it's a private insurance a copy from the insurance company or to obtain a summary of benefits.

JoniB · March 2016

i experienced the same aggregation in 2008. I never wrote down who told me the doctor was in network but I don't think that would have mattered. She was in network at one location but not mine. The insurance company and hospital would not budge. I reached out to my assembly woman - who I did not know personally. They placed a call to the insurance company who agreed to.cover the doctor in network. You may want to try that. They have connections and I think it was an intern who did.all the work!

rainnyc · March 2016

I would agree with what Joni says. When I ran into an insurance issue--not the same as yours--the social worker at the hospital told me that if all else fails, start getting in touch with elected officials and make some noise. According to her, they have a surprising amount of behind the scenes clout. This is at a NCI designated cancer center.

vlnrph · March 2016

Another government approach is to contact your state insurance department commissioner's office (perhaps something to try prior to jumping up to the federal level). I will bump an older post describing my experience. The company can be fined and made to pay interest if they are withholding coverage/payment or operating in bad faith.

mairew · March 2016

Hey guys, just updating with news. The clinic called to say that they will only bill me for my share of what should have been the "in network" co-insurance amount. Unfortunately, they are handling this internally and basically eating the insurance company's amount, which means any amount I do pay will not go towards my insurance company's in network out of pocket max. Meaning I will have to pay that amount twice. I brought this point up to the clinic office manager and she is calling BCBS. But I already discussed the out of pocket issue with BCBS and they said they consider any payments to this physician out of network.

So the saga continues. I will let you know what happens next. This was the clinics error and I appreciate then trying to fix it, but I should not have to pay more towards meeting my out of pocket max.

vlnrph · March 2016

At least there was a little progress made. Being charged twice toward your out of pocket max is still a problem.

Ask about getting written documentation of the clinic manager's interaction with BCBS. The phone call should be recorded. It would be interesting to find out how vigorously they defend your position. I suspect not much.

You may need to continue your own efforts. Don't take the first insurance company opinion as your final result. Perhaps a formal appeal/grievance will be required. Their goal is to prevent your non-network payment from being applied to your account however you shouldn't be penalized for provider error! You deserve credit for that amount.

Clinic verified BS in network, but Ins said out of network

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