Out of Network Anesthesiologists

Discussion in 'General Parenting' started by Stella Johnson, May 5, 2004.

  1. Stella Johnson

    Stella Johnson Active Member

    This isn't difficult child related.
    A friend had her baby by csection about a month ago. Turns out the anesthesiologist that she had was not in her network.

    Her ins co is saying they will ONLY cover 40% instead of the usual 90% because the doctor was out of network. You don't have a choice who you get in the hospital.

    I thought there was a state law of some kind for this. If so, can you tell me where to find it? I am in Texas.

    Thanks and Congratulations!

    Steph
     
  2. kris

    kris New Member

    steph, when i was in hospital...each time....there were docs not in my network who treated me. because the hospital was in~network their services were covered. don't know if that is a florida thing or not.

    kris /importthreads/images/graemlins/smile.gif
     
  3. mose

    mose New Member

    A person has to know this information to not get swindled by doctors!

    I don't think it's just Fla, the same thing happened here in NY when my daughter was born. Then when my husband was treated by out of network anesthesiologist during minor surgery. No one gave us a choice or told us we had a choice. I was so pissed, And I did not pay more then what my HMO reimburses.
    Your friend needs to call the doctors office and tell them she can not afford to pay more then her HMO reimburses.

    I had to fight and convince the out of network doctor that this was his responsibility since he freely choose to take us on without checking if he will be covered and we had no choice!!!
    I was not paying him a penny more than the reimbursement rate he got from my HMO.

    We were one less sucker that he swindled into paying the inflated per "minute" rate he charged.

    Mose
     
  4. Nancy

    Nancy Well-Known Member Staff Member

    I recently got a $660 bill for a doctor who did an upper GI endoscopy on my daughter last year. Our pediatric gastro who did the colonoscopy and biopsy is in our network and her services were covered. I didn't know we were getting another dr to do the upper GI stuff.

    I called the hospital and told them it was not my fault that they used a dr who was not in our network and I was never told this dr would be doing anything on my daughter.

    That was in February and I have not gotten another bill since.

    Seems like a scam to me.

    Nancy
     
  5. bigblueagain

    bigblueagain New Member

    usually the insurance carriers will waive the out of network on anesthesiologists, as most of them( Anesthesiology groups) function such that they aren't in networks. Not sure exactly how they can do it, but suffice it to say they can and do. The hospitals know this, and if the hospital was in your network they should be allowing payment at the in network level(the anesthesiology group that is should be willing to take that level of pay as they know most hospitals are in networks....THEY are the ones who are choosing not to join the networks.) I would start with calling your insurance provider and asking for a customer service supervisor. Explain the situation and if they cannot resolve it for you, ask for the appeal process on claim payment. Would also go ahead and call the anesthiology group's business manager and tell them that you had no choice, you were at an in network facility that THEY chose not to participate with, and that you will not be able to pay more than your carrier covers. If you have an HMO product, they have to accept what your HMO pays when it gets right down to it. Many times they try this cause they know most lay people won't know how to fight them on it and will just pay!!!!Might also want to check your benefit booklet that should give you an page under which benefits payable to is listed. There should be a listing for hospital and surgical charges that should also include anesthesiology charges. Let me know how it goes! BLUE
     
  6. LisaG

    LisaG New Member

    This thread caught my interest because this is what I do for a living. I handle billing, collections and contract negotiations for group of anesthesiologists. Before that, I handled billing issues for a major metro hospital. Please don't put me on any of your "most-hated" lists, but accurate information may get you far if you understand how the system works. It changes constantly and the only way that you will stay on top of it is to keep asking questions and to know your insurance benefits thoroughly.

    First of all, most insurance companies (I'd say about 90-95% of them) know that patients do not normally have a choice of anesthesiologists. This will depend on where you live because in some areas of the country, the doctors are contracted to a particular hospitals, and in others, they can practice at any hospital (this is the case where I live). Most will give you credit for having no choice, but their claims processing system cannot do it automatically...not "smart" enough. A person will normally have to override the system to accomplish this.



    Anesthesia is billed in time increments. Each procedure starts with a base value and the charges increase for each 15 minutes of time. The time increment can vary from practice to practice, but 15 minutes is the most common. Medicare processes the time by the minute. The longer that the doctor or CRNA (certified registered nurse anesthestist) is in attendance the higher the charge. Both specialists can bill and are reimbursed the same. Insurances are notorious for not processing all billed units, but a patient would have no way of knowing unless they ask both the physician and the insurance for comparisons. Trust me, insurances often make mistakes. (I know because I spent all day today writing disputes, appeals and requests for corrected payments!)



    First of all, appeal to your insurance carrier and emphasize that you used an in-network surgeon/provider for the actual procedure and went to an in-network facility. Point out that you were not allowed any choice of anesthesiologists. This can often be done over the phone, but a few plans will want it in writing. Almost all of the time, they will reprocess the claim and possible reduce you balance. The biggest problem will be for patients who have seperate deductibles or lower coinsurance amounts for non-participating doctors. But don't give up...many plans will even pay these amounts to the physicians when you appeal so that you are not penalized.



    In the event that your plan will not reconsider or you are still left with a large patient portion because of the doctors network status, contact the doctor's office to discuss arrangements with them. I am very thankful that I work for an office that maintains an office policy that we never penalize a patient for the out of network penalities. My group of physicians will fight with the plans for additional payment, and if refused, will waive the penalties and only collect the normal in-network patient amount from the patient. But I will say that this is rare. Most physicians don't do this, but it never hurts to ask.


    Most important, STAY CALM AND FRIENDLY no matter how upset you are. Starting the conversation with a tone and an attitude will probably make the account rep less likely to cooperate. We are just doing our jobs and don't make the policies usually. But we often have more power then you think and may be able to assist you in some way. It is very difficult to want to go out of our way to help someone who is being nasty and not listening.



    The reason that many anesthesiologists do not belong to plans is that the plans make it extremely difficult to get a decently reimbursing contract. The smaller the group of doctors, the harder it is. Many are left with no choice but to not take any contracts and hope for better reimbursements in the long run.





    Don't waste your time talking to a facility about a physician's balance either unless they are contracted to do their billing, or unless the doctor is an actual employee of the facility. A provider on staff is not an employee. The hospitals DO NOT and CANNOT control what plans any physician belongs to. The doctors are individual companies and have a right to contract or not contract with any plans that they desire. A hospital cannot force a provider to accept a particular insurance payment as payment-in-full either. They would not even consider asking that since they have no legal or ethical right to do that.


    I know that I have probably just opened a can of worms, but I only wish to help everyone get the most from their insurance companies that they can. I have worked in hospital billing as well as surgeons, assistant surgeons, anesthesia, PT, Occupational Therapist (OT), family practice, and laboratory. Let me know if you have any questions and I will try to answer them for you.
     
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