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.
