# OMG now what are we going to do?!UPDATE 7/2



## triste (Aug 30, 2004)

My husband just had a meeting with our health insurance rep. I'll start last August. As some of you know, I had a hysterectomy last year. Well what no one told us until NOW is that my doctor (that I've seen since I was 18 and I'm now nearly 35)...was not part of our network as of June 2006.







WHAT IN THE HECK?! The office of the doc is saying they were not notified of the change until September. SO, since the doc did the surgery while not in our network, we are potentially responsible for $10,000 worth of medical bills that should have been covered 100% b/c at that point we met our out of pocket max for me. If the doctor's office went through the proper channels, my surgery should have been precertified. If they did this, then the insurance company messed up and it shouldn't be our responsibility. If the doctor didn't call, then it's their fault for not precertifying it. We haven't heard back from the doc's office..but this is one HUGE mess.


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## Chyna's Mommie (Feb 23, 2007)

Go speak to a lawyer. The doctors office is going to try to cover themselves & the insurance company is going to do the same. You are going to be the odd man out unless you get someone on your side. I've never heard of a patient having to contact a insurance company regarding a procedure unless its something that the insurance doesn't usually cover.


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## msmagnolia (Sep 8, 2004)

Oh no! I don't blame you for stressing about this problem. Are you saying that the doctor's fees are the ones in question? I assume that they paid the hospital charges, etc. Seems like the doctor's insurance person screwed up. My husband's office doesn't participate in any HMO's but their insurance person checks on all insurance before surgery.


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## Scoobydoo (May 26, 2005)

Oh gee I am so sorry, it sounds like the doctor's office has let you down really, I thought they are supposed to notify your insurance pre surgery, or at least ours does. If we are referred to a specialist for any procedures our doctor's office will make sure they send us to one on our insurance listing.
I agree that you should seek legal advice and find out who is resposible in your situation. I sure hope you can get this resolved in your favor


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## schatzi's mom (May 13, 2007)

I'm not surprised. The same exact thing happened to me as well







Down to around the same date. the only difference is that my costs were a lot less (around 400) and it wasnt my doctor that was out of network, it was the lab that they send bloodwork etc to. Anyway technically it was the doctors fault because they didnt check with my insurance to have the lab approved before they sent it off so they were responsible. At first they agreed to pay but NEVER did







They put me through the run around for a good 6 months until the lab was going to report me to the credit agency







Finally I was so fed up that I complained to my insurance and filed an appeal through them and they ended up covering the costs even though they werent the ones responsible. maybe that's a route you could try? If not I would definetly get a lawyer involved.


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## cruisinpat (Jan 29, 2007)

Years ago something similar happened to me only on a much smaller scale. After months of arguing with the doctor's office I did not pay the bill. I always check out my benefits and he misinformed me. My argument was why should I pay for his mistake.
I believe in the end you won't have to pay the bill but you'll have to fight for your rights. A lawyer isn't a bad idea. It will save you a ton of headaches and countless hours on the phone. Good luck and keep up informed with the progress............................Pat


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## saltymalty (Sep 14, 2004)

I have a couple of suggestions before you go through the expense of hiring a lawyer. First, check with your insurance company. Make sure you have copies of all statements, payments by the Insurance company to the doctor as well as those made to you. Read your coverage...it's usually a good idea to do this any way, but most people don't. Talk to the insurance rep and find out if the doctor is at fault in their mind. Talk to the doctor and see if the they think the insurance company is to blame. Usually you'll be able to figure out who made the mistake that way. But if you cannot, call your county or state office of consumer affairs, insurance commission, or whatever state agency is responsible for oversight of insurance disputes. It's hard to say without knowing all the details, but it sounds like the doctor's office messed up the insurance claim. If you don't get any satisfaction from your insurance company, your doctor, or the state government go to see your Congressman. They have caseworkers in their district offices that work on this kind of thing all the time.


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## MalteseJane (Nov 21, 2004)

All this would not happen if there would be a Universal Health Insurance.


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## Bijousmom (May 29, 2005)

> All this would not happen if there would be a Universal Health Insurance.[/B]


 

Amen and I agree with you totally. The scary part of insurance is that even if you have health insurance will they try to get out of paying anything. I usually joke at the doctors' offices that we only give BC/BS of Tennessee money but we don't expect them to pay anything.


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## sassy's mommy (Aug 29, 2005)

Contact an attorney before you let them bully you into paying anything. Sounds like someone other than yourself is liable.


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## Tina (Aug 6, 2006)

> Go speak to a lawyer. The doctors office is going to try to cover themselves & the insurance company is going to do the same. You are going to be the odd man out unless you get someone on your side. I've never heard of a patient having to contact a insurance company regarding a procedure unless its something that the insurance doesn't usually cover.[/B]


 

When I worked in a MD's office, it was the nurse's responsibility to precertify before the procedure. We did it on all laser procedures. But, then as a patient I have had to call my insurance a few times to be precertified for procedures. Especially if it was out of the network. Your insurance company should have sent you notification that your doctor was no longer in their network. Insurance companies more or less control what doctors can and cannot do, unless you pay for it yourself.

If I were in your shoes, I would be hopping mad too.

Tina


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## gottagettamaltee (Dec 1, 2005)

I was in a similar situation with my car insurance. I forgot to pay my last payment, so instead, the insurance company sent a letter saying I didn't owe anything until my new year started over (they just added my old balance to the new balance) so I didn't have to pay for another month or two and I shrugged it off. Well, a week or two later I got into a car accident and the insurance claims rep told me that I was not covered, recorded our conversations where he asked me a series of questions about me missing my last payment. He told me that I needed to have my car towed to somewhere else other than the place it was stored at because they were not going to pay for it and I'd be responsible for the charges of storing it. I tried tot ake care of things but it was no use. My Mom talked to her lawyer and he called the insurance company and also talked to his superiors and sent them a letter. I also talked to a rep at the local insurance branch and she made some phone calls and she told me that I had coverage and the guy who was the claim rep was trying to find some kind of fault so they could deny my claim. (I don't know why, it's the insurance co. paying for it, not him. He acted like it was _his_ money or something). So they ended up assigning me a different claims rep. They paid out a little over $8000 for repairs on my car and I had to pay my $1000 deductible.



From what I understand, it is the doctor's nurse's job to communicate with the insurance authorization reps and get authorization letters that go in the patient files before having surgery. If those aren't done or the surgery takes place before authorization and later comes back as not covered, then the doctor doesn't get paid. If it's a major surgery or something that has to be done right away, like a life or death situation, then the patient or responsible party has to sign an agreement that they are financially responsible if the insurance doesn't authorize the procedure. The doctor's want to get paid and when something like this happens, it's usually because someone else has messed up. That's basically what I was told by the supervisor of the insurance authorizations dept at the medical clinic. She told me that when a high cost procedure already is done but ends up being unauthorized, it's between the nurse and the insurance autho rep because either the nurse didn't submit it to the rep or was late in submitting, or the rep didn't do it or was late in contacting the ins. co.

Insurance companies are rediculous. They are quick to take your money and give you a card that says you have health insurance but when it comes to them paying for your procedures, there's always something that they aren't covering or are only partially covering because of their own reasons. I know about that, I do some insurance billing for a dentist.


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## 2maltese4me (May 8, 2006)

This happend to me 2yrs ago with an MRI. I told my doctor I could only get one done at certain places..she checked and referred me to a hospital that "was covered". When the hospital called me to set up the appt, I had them double and triple check...she said yes, all I had to pay was my co-payment of $150...ok, fine. WRONG. I got a bill for $2500.....I had no choice but to pay even though I kicked and screamed, in the end, *I* should have called my INS co myself to check it out, instead I relied on others and took their word, never again. 

Be careful, they will send you to collection if you don't pay. At the same time, tell them you can only pay $25 a month (or whatever) and they should set you up on a payment plan.

Good luck.....


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## triste (Aug 30, 2004)

on the precert note, it says that there's not 100% guarantee they'll be covered







WHAT IN THE [email protected]


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## gottagettamaltee (Dec 1, 2005)

> on the precert note, it says that there's not 100% guarantee they'll be covered
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I don't know how similar dental billing is to medical billing, but in dental billing you can request a preauthorization for services. True, it doesn't 100% guarantee it, but with dental, it has to do with if the procedure is needed or mandatory, if there is an alternate/cheaper procedure, if it's "elective" or "cosmetic". Then if it's a procedure that it needed and whatnot, you have to make sure you have certain paperwork, xrays, etc. and if you don't have ALL of the attachments needed, they don't pay for it. 


I don't like the insurance companies, they should make it clear if they pay for crap or not. Why make it a guessing game? 
Honestly, I think your doctor's office is the one at fault because whenever a patient comes into the office I work at and they have medi-cal or private insurance or even the contracted insurance "in-network" types, we always call to make sure they are eligible and they always tell you if they are on one of those plans that doesn't allow "out of network" doctors. The last time I called on an "in network" only plan, the dentist had already done the work on the patient and I hadn't been in for a few days, so that was free work for that patient, plus they got to save on their yearly max allowance. 
I know every time I go to my doctor, they get preauth's from my insurance over the internet and staple it to my paperwork. 
Seriously, someone must've screwed up somewhere down the line and now you have to pay for the consequences?? It's bull.


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## MissMelanie (Feb 13, 2006)

> > index.php?act=findpost&pid=397926
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Ditto for me. Heck, you almost can't walk into my doctor's office without being "patted down" for insurance coverage it seems. LUCKY those that have it!



I am so very sorry for you Triste. What a shame that due to someone's lack of doing THEIR job you have had insult added to injury to deal with. I wish you well. God bless.










Melanie


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## triste (Aug 30, 2004)

We've gotten the "final" word from the insurance company. They are NOT going to cover it. They said someone signed for the certified letter saying the doc was being dropped from the network...the doc says it must have been someone at the hospital that he works out of b/c they didn't receive notification until September. So..hubby asks doc office what should he do? They said to wait until the office manager is back from vacation and "we'll see what we can work out".







That was supposed to be covered 100 FREAKING PERCENT b/c we met our out of pocket for the year. Now..we're paying SOMETHING and that SOMETHING is more than we should be paying!


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## Suz & the Fluffs (Mar 11, 2006)

> We've gotten the "final" word from the insurance company. They are NOT going to cover it. They said someone signed for the certified letter saying the doc was being dropped from the network...the doc says it must have been someone at the hospital that he works out of b/c they didn't receive notification until September. So..hubby asks doc office what should he do? They said to wait until the office manager is back from vacation and "we'll see what we can work out".
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I'm sorry.







Thats just awful! I hope their office manager can work out something with you. I would be soooo mad if I were you as its their fault.


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## The A Team (Dec 1, 2005)

But it's the doctors office fault. Not yours, why should you have to pay for someone else's mistake? That's just not right.


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## saltymalty (Sep 14, 2004)

I would suggest that you send the doctors office a certified return receipt letter stating exactly what you did to comply w/your end of the agreement and why you should not incur any charges. Reference the conversations you have had with his office using as much information as possible, including dates and times. Include language that states this obligation was covered in full and that you do not intend to pay any additional fees or charges and that they should cease and desist from sending you any additional bills or charges related to this event. Attach a copy of the certified letter the insurance company sent to your doctor as well as any other relevant information. If that doesn't give you satisfaction, then seek legal counsel.


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## msmagnolia (Sep 8, 2004)

> I would suggest that you send the doctors office a certified return receipt letter stating exactly what you did to comply w/your end of the agreement and why you should not incur any charges. Reference the conversations you have had with his office using as much information as possible, including dates and times. Include language that states this obligation was covered in full and that you do not intend to pay any additional fees or charges and that they should cease and desist from sending you any additional bills or charges related to this event. Attach a copy of the certified letter the insurance company sent to your doctor as well as any other relevant information. If that doesn't give you satisfaction, then seek legal counsel.[/B]


Ditto!
And Denise, just because this doctor has been your doctor for a long time, doesn't mean that you should have to pay for their mistake. Meanwhile, you might be needed to start getting recs for a new doc!


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## hambys97 (Feb 25, 2005)

I hate to be the "black sheep" here, but I have been dealing with the insurance nightmare more than I would like to admit due to some medical issues. The bottom line is that it is my obligation to verify what is or isn't covered under my insurance. It isn't my doctor's responsibility, while it is helpful. I appreciate all the information that the offices do provide, but at the end of the day it is my coverage, under my insurance plan. While insurances offer so many plans, it is difficult for the doctors to keep up with what each plan under each provider will/won't cover.
I do hope that things can be worked out. And if this is a doctor that you have had for that long, I would imagine that you have a good, trusting relationship with him. I don't think this is something any one would intentionally do. I don't feel that you should be expected to pay full bill. I am hoping that there is a happy ground in the middle that you can both live with. Sorry, JMO.
I do NOT like insurance companies at all. I think that as the "civilized" "leading" nation that we are here in the US that we should realize that if another country has a medical system that works with little negative then we should follow. What is wrong with this country that it has now become a right to "screw" over the little people to allow for those big bottom lines????


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## triste (Aug 30, 2004)

A patient should NOT have to check if the doctor is still in the network every time they go to the doctor ...and the doctor's office tells you they called and precertified the surgery, why would you have any reason to call on your own? It's not a matter of if the plan covers it, it's a matter of a big insurance company dropped him from their coverage. When he called to precertify me, the insurance company KNEW that they no longer had this doctor in their network yet they still okay'd the surgery. If we had called, they'd have told us the same thing. If I checked every time I had myself or my children at the doc's office..I'd be on the phone all the danged time!


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## MalteseJane (Nov 21, 2004)

Are those 10,000$ only doctor fees for the surgery ? 3 years ago to remove my tumors I paid only 4,000$ for my doctor and 1,000$ for his assistant. I have good insurance, tankgoodness, I can go with any doctor I want and am reimbursed 100%.


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## triste (Aug 30, 2004)

Yes, that's doctor fees only. I had a hysterectomy, bladder repair and rectocele. The "works". It was a 3hr surgery. That includes any and all preop work they did as well as post between June and Sept.


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## MalteseJane (Nov 21, 2004)

You had 3 things done, that makes more sense then. My price also included post op care.


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## MissMelanie (Feb 13, 2006)

I am so sorry but I still feel this problem is the INSURANCE'S AND Doctor's issue. NOT your's.

Melanie


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## gottagettamaltee (Dec 1, 2005)

> A patient should NOT have to check if the doctor is still in the network every time they go to the doctor ...and the doctor's office tells you they called and precertified the surgery, why would you have any reason to call on your own? It's not a matter of if the plan covers it, it's a matter of a big insurance company dropped him from their coverage. When he called to precertify me, the insurance company KNEW that they no longer had this doctor in their network yet they still okay'd the surgery. If we had called, they'd have told us the same thing. If I checked every time I had myself or my children at the doc's office..I'd be on the phone all the danged time![/B]


maybe a patient calling to make sure their coverage is effective is a safeguard against mishaps like this, but at the same time the doctor's office always calls to make sure that you have coverage when you visit and they have to do more than just make a phone call for a major surgery. they do that to ensure they get paid by the insurance company and if they arent covering it then they have to notify you of that so you can talk to the insurance company or agree to pay out of pocket.. this is just wrong! i think you should keep on their butts because both the insurance company and the doctor will do what they can to keep from eating the bill themselves. as long as they can tell you that you are at fault and have you believe that there's nothing you can do about it, then the insurance company doesn't have to pay and the doctor doesn't have to eat the bill if it's his staff's mistake. i know all doctors around here have an employee that does nothing else but deal with the insurance companies like precerts and communications. doctors offices usually ask for your insurance card every time you visit and that's so they can check to make sure you currently have coverage and are eligible for benefits. don't let them stick you with the bill. have you talked to an attorney yet?


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## revakb2 (Sep 8, 2006)

I would keep trying with the insurance company and your doctor. I would also send copies of your corespondence to the insurance commission in your state. With this said, you still may not win. Unfortunately, even though you are in the right, fighting the bureacy can be a losing battle. If all else fails, you can make payments monthly to the doctor. My friend went through a similar situation. She is paying for cancer surgery at the rate of $30.00 a month. As long as you pay something every month, the doctor will probably not send you to a collection agency. I deal with credit issues everyday, and the most common issue on credit reports is medical collections. Most of these collection items are for people with insurance coverage.

I certainly hope you can get a resolution from the insurance company. Try finding out the name and address of the CEO of the insurance company. If you can get an executive to get involed in this matter, maybe something can be worked out. Good Luck.


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## hambys97 (Feb 25, 2005)

I am hoping for some kind of positive outcome for you. I wasn't trying to imply that anyone should have to call prior to EVERY visit. All I wanted to share was my feelings that unfortunately we live in a society that is run by the large insurance companies which leave our medical care in the hands of someone without any medical training. Prior to all my medical issues, I was in the same mind frame as most in thinking that it is the doctor's office to verify what is covered/not covered. But unfortunately I have since learned that this is exactly why there are many doctors offices who no longer offer to file insurance claims on behalf of their patients. They require up front payments and then let you file and wait for compensation.
Just as an example, I went for my dental cleaning on Tuesday. I have TMJ and grind my teeth horribly. I have done some damage to my teeth, and really need to have a splint custom made. I have tried everything possible over-the-counter to work without any success. My only option now is this custom made splint. I inquired on the cost, and if they knew whether insurance would cover any of that cost. The office staff were all extrememly nice in explaining that the splint cost was $449, and they show that insurance would POSSIBLY pay for $199.50. They even went further to share that my dentist does not send just the standard form, he also writes a letter to the insurance explaining in detail the necessity of the splint. They shared also that the information they have is only an estimate, and does not guarantee or obligate them to pay that amount.
I asked what they would recommend that I do. I was told that they would recommend that I personally call the insurance, but to keep in mind that even then they (the insurance company) would not guarantee what if any they would pay. The final determination would not be made until the claim had been submitted and processed.
All I wanted to share was that until something is done to FORCE change by the insurance companies, we are stuck with what we have which is mediocre at best.
Again, good luck in finding a suitable solution.


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## saltymalty (Sep 14, 2004)

Just an FYI...insurance companies will not allow patients to pre-certify themselves. That must be done by the doctor's office. It seems from what Triste has said, someone in the doctor's office make a major mistake. Triste I would demand that your doctor provide you with your complete record and insurance correspondence. I would also recommend that you issue a similar demand to the insurance company for their records relative to this procedure. I would definitely not give up...by law they have to allow you to see your records.


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## Princess D (May 16, 2007)

I would try contacting the ombudsman office at the hospital and making a formal complaint and also the billing department, they have financial assistance for people that have insurance and jobs, but still have medical bills. It would really be worth looking into.


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## Scoobydoo (May 26, 2005)

When I had to have my veins done in my left leg last year our insurance wasn't going to cover it claiming it was cosmetic so the specialist who was performing the procedure contacted them by letter explaining that it was necessary for my health. I also took pictures because the insurance insisted that I wear support hose to correct the swelling and control the problem. This did nothing for me, in actual fact it made my problem worse because the problem vein was behind my knee and the stockings just made my leg swell even more. What I did was take pictures of the before and afters along to the specialist, he forwarded them to the insurance company along with the letter and next thing we get a call from our insurance saying to go ahead and have the surgery done, they were then willing to cover the cost.
My point here is that some doctors do contact insurance companies to make sure their patients are covered before they go ahead and schedule any surgery.
I don't understand how your surgeon or his staff could let you down so badly, even our GP's nurse will check our insurance listing before referring us to any specialist for treatment or surgery. We also have a yearly book that is sent to us from our insurer with all the doctors that they cover.


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