Issues in claim processing:Insurance (medical, plan, hospital, doctor)

[phoenix_new]

we had a baby last month, so all the claims are being processes by the Insurance company, there is one claim, which is processes out of network. Don't know how that happened. There was one Surgical Assistant during the delivery, he send a claim of $2750.00 to the insurance company, Now here is the Explanation of benefits by insurance company:

Bill received: $2750.00
Member rate: $330.00
Not paid by plan: $2420.00
Amount toward meeting deductible: $150.00
Coinsurance: $54.00
Your total responsibility: $2624.00


How the hell I am gonna pay this amount ? Please let me know what shall I do ?

[lubby]

Originally Posted by phoenix_new

we had a baby last month, so all the claims are being processes by the Insurance company, there is one claim, which is processes out of network. Don't know how that happened. There was one Surgical Assistant during the delivery, he send a claim of $2750.00 to the insurance company, Now here is the Explanation of benefits by insurance company:

Bill received: $2750.00
Member rate: $330.00
Not paid by plan: $2420.00
Amount toward meeting deductible: $150.00
Coinsurance: $54.00
Your total responsibility: $2624.00


How the hell I am gonna pay this amount ? Please let me know what shall I do ?

plan
Did you call your insurance company?? Is this bill from the Hospital?? Maybe they can set up a payment plan for you. I know Hospitals by me on LI do that.I had a procedure done in the hospital (D&C) the anethstesiologist was not on the plan (out of network) I received a bill from them for about $1,500, I called oxford right away and they said even though it was out of network it was done in the hospital and it would be covered. I called the Anethstesiologist office back to tell them oxford would be sending a check. 1 week later I got a letter in the mail that the Dr. was paid.

[phoenix_new]

Originally Posted by lubby

plan
Did you call your insurance company?? Is this bill from the Hospital?? Maybe they can set up a payment plan for you. I know Hospitals by me on LI do that.I had a procedure done in the hospital (D&C) the anethstesiologist was not on the plan (out of network) I received a bill from them for about $1,500, I called oxford right away and they said even though it was out of network it was done in the hospital and it would be covered. I called the Anethstesiologist office back to tell them oxford would be sending a check. 1 week later I got a letter in the mail that the Dr. was paid.

This is EOB on Insurance company website, haven't heard anything from Hospital yet, do you think I should contact Insurance company right away OR wait for bills from Hospital ?

[lubby]

Originally Posted by phoenix_new

This is EOB on Insurance company website, haven't heard anything from Hospital yet, do you think I should contact Insurance company right away OR wait for bills from Hospital ?

Call insurance company right away, did you receive a letter from them stating you owed that amount???? Then I would contact the billing department at the hospital.

[reed303]

The key here is the title "Surgical Assistant". This happened when my wife had ortho surgery. When you sign the paper work with the main surgeon, and the hospital, it says you are responsible for all charges by *any* providers called in to assist. Not sure about others, but in State of Colorado, SA's are not licensed MD's, the ortho MD can literally grab a cab driver in the waiting room, have him hold a clamp, and be called a SA, and submit a bill to patient. Hospital would not get involved at all, Ortho doc said "I needed help, this was cheaper than another Ortho". Ironically, Insurance said they would have paid for a 2nd Ortho, but not an unlicensed SA . They did pay 50% as "out of network", but I was stuck with balance.

2 years later when wife needed same op on other shoulder, we tried to confront the ortho about this, but he would not budge. As wife was in such pain, we went ahead. Same bill, same treatment by Insurance.

Personally I believe that some surgeons have found this method as a way to increase their income. I have not doubt the SA in this case split the money with the MD. ( I further suspect the SA was the MD's partner's wife )

Anymore it seems you need to have a lawyer present at anything more than a routine office visit.

[phoenix_new]

In my case, this happened during a C-section delivery, at that time Hospital should have taken care of this, they should have allocated a In-network SA.
Now I talked to Insurance company, they will review the claim again.

But what if they don't pay anything ?

I have one more question, let's say if SA was in-network then he would have got Insurance company negotiated rate i.e. $300.00 ? correct ?

I am ready to pay him that ammount, do you think it makes sense ? WHY WOULD HE NEED $2700.00 just because he is Out of network ?

I JUST DONT GET IT, HOW THIS SYSTEM WORKS.

[AnonChick]

He needs $2700 for out of network, *because* he agreed to only take $300 in network. Insurance company schedules of payment are notoriously low. So doctors have to make up for it by overcharging out the wazoo, when they are able.

Notice he submitted the full $2700 to the insurance company and they rejected everything -except- the $300. His fee IS $2700. The insurance company refuses to pay the fee, and comes up with a fee they -are- willing to pay, and even then, they only pay a percentage, and you have to pay the balance.

That's how network insurance works.

It sucks, but that's how it works.

[phoenix_new]

I understand, now how do I get out of this ? there is no way I can pay $2700 to anyone at this time, Plus I already have to pay $1200.00 for regular deductibles and co-insurances.

[Padgett2]

You can't really get out of it. You owe it. You pay it. It's bad news, but that's the way it works.

If you don't, or if you contest the amount, it will probably be turned over to a collection agency.

[phoenix_new]

do u think medical provider will negotiate ? or do they normally negotiate ?