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I received a common treatment after a back injury with a doctor that I found on my insurance company's website (United Health Care). I called the doctor and he confirmed that he is on the provider list. It seemed simple. Then.... My insurance company denied the benefits because he is NOT on the list. They say there's a many types of provider lists and I should have looked under my specific plan, not the general list on their website (How am I supposed to know? Obviously even the doctor's office didn't know this).
I appealed on the decision and I am wondering if I should pay the doctor myself in the meantime. I did an MRI testing because the office told me my plan would cover 100%. If not, I am in big trouble... Our health care system is sooooo broken!
I received a common treatment after a back injury with a doctor that I found on my insurance company's website (United Health Care). I called the doctor and he confirmed that he is on the provider list. It seemed simple. Then.... My insurance company denied the benefits because he is NOT on the list. They say there's a many types of provider lists and I should have looked under my specific plan, not the general list on their website (How am I supposed to know? Obviously even the doctor's office didn't know this).
I appealed on the decision and I am wondering if I should pay the doctor myself in the meantime. I did an MRI testing because the office told me my plan would cover 100%. If not, I am in big trouble... Our health care system is sooooo broken!
This happened to me with a dentist. I had back surgery, then a few weeks later broke a tooth. The dentist swore they were in plan. I go for my appointment & guess what? They stopped taking my insurance. What an expensive day that was.
I hate going online to see who is in network. They usually have so much fine print, well, this isn't covered unless it's an emergency, then you call before taking your kid to the ER, they say go, only to get a huge bill in the mail that you have to appeal.
Hopefully for you the MRI will be covered but you might have to pay the office visit. I would call their billing department, tell them they were partly at fault and see what they could write off. I'd then say I can pay 50% now, assuming you can. Most will work with you.
You said you found the doctor on your insurance company's website; did you go through their website program and pick YOUR plan? I'm not sure how else you could have found a doctor there unless you did that. I would definitely fight this as I've been told that the website may not be as current as the doctors' billing department. If the MD's office said that they took your insurance, I'd take their word for it.
I can tell you via personal experience with UHC that you can NOT trust their website to be the most current and up to date info. When I find a doc or facility online, I ALWAYS call the customer service department to confirm the doc/facility is still in network for my particular plan. Some doc's wont take the HMO UHC product because reimbursement is so low. Same for their medicare plans. Just because a doc's office consider themselves "in network" doesn't mean they know exactly what contract was signed by the doc or his representative.
If you have NO out of network benefits, you're probably going to have to eat the cost of all treatments ordered or rendered by the out of network provider. While you can fight this, it is your responsibility to know your insurance plan inside and out. If you had gone online, found this doc with the website showing he was in network for your plan, printed the screen and kept it for your records, you would have a slam dunk appeal they couldn't refute. But if you found his name in the general directory and then took the word of the person at his office who did not bother to confirm your actual plan, you will probably be held responsible. Then again, it depends upon your plan (HMO, PPO, POS...) and the state in which you live.
Typically I do not recommend paying any charges until the insurance company pays their part. If your doctor's office is OK with you holding off until after the appeal, this is what I'd do. At least pay the copay or your part of what it would have been. I would venture that in the end, they will probably just eat the cost of the visit. Now that facility that performed the MRI will probably not be as generous. However, they too should have verified your benefits prior to rendering services. If they had done their job correctly, their insurance verifier should have noted that your doc was not in network for your UHC plan. If you have out of network benefits, they will charge you the out of network rate. If you have no out of network benefits, they should not have performed the MRI without confirming with you that you understood the cost would be at the out of network rate (100% your responsibility). So even if you loose your appeal with UHC, you could use this as leverage with the MRI provider when you are making payment arrangements.
If your initial appeal is denied, you will receive instructions on how to go to the next level. It is important that you follow these steps exactly. You may have to go through a second level appeal. And if you're lucky to have a plan that allows an outside party to review your appeal, you stand a much better chance. I know how frustrating it is to try to manuever through the maze known as managed care. But you have to remember that the only person truly looking out for your best interest is you, especially when it comes down to the money aspect. Good luck.
Last edited by mckinneydeb; 09-14-2008 at 03:39 PM..
The doctor's office should know better than the insurance company's website whether or not they are participating providers. Any insurance company's website is not as up to date as the doctor's contract with them. Even customer service people at the insurance company only reads a list which is the same as the website. I had a similar experience with a doctor once who claimed that a PET scan was precerted with my insurance company. Because I did not always trust anybody when it comes to very expensive procedures I called the insurance company to verify. Doctor's office did not only fill up the claim form correctly causing the claim to be considered experimental and the claim was denied. But because of e-mails between the doctor and myself, I had proof that they confirmed it was covered. The doctor ended up writing off the procedure with no adverse effect on my credit. My advice is always to check with both parties if in doubt, get names of people you spoke to and the dates you spoke to them, and create a journal of your communication with everybody. You will strengthen your case in case a dispute on coverage arises.
I appealed on the decision and I am wondering if I should pay the doctor myself in the meantime. I did an MRI testing because the office told me my plan would cover 100%. If not, I am in big trouble... Our health care system is sooooo broken!
Talk to the doctor, tell him your are appealing and see if he will agree to not report you to the credit bureau, etc., while the appeal is being processed. If he agrees, be sure to keep in touch with his office regularly so they know you aren't ignoring the situation. If instead he wants to be paid now, I would pay, rather than risk my credit. Perhaps he can work out a payment arrangement with you. Same with the MRI. I am familiar with the dealings of insurance companies and the first time I see a new doctor, I always call and confirm. It's tedious but it saves a lot of stress later on. Best of luck on your appeal.
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Our health care system is sooooo broken!
