Doctor in network but their office isn't: Appeal?

[ltravisjr]

I have a dispute with my health insurance company and I don't know my recourse. The short story is my wife got hearing aids which are covered under our plan from an in-network audiologist. However, the doctor works in an office which is not in the network and the insurance saw that and thus paid a fraction of the allowed amount. They suggested we get the audiologist's NPI number and send it with a claim resubmittal and that that should resolve it. However, we did that but they just repeated that the group wasn't in network and kicked it into internal appeal.

So, at this point I am wondering how insurance companies are required to deal with in-network doctors in out-of-network offices when processing claims. Also, if this appeal doesn't end in my favor, I wonder what my recourse is because I don't think this is an issue that would qualify for external appeal.

Any help at all would be most appreciated!

 

[YouGotMyMoney]

Did you use the in-network VENDOR for Hearing Aids?

 

[leevena]

This is not that all unusual. It can be possible for Dr. A to be part of a practice that is in network, and that he can also practice at a second location that is not participating. The key is how the provider contracting is structured, most are at the practice level, not the individual provider level. It does appear as though you will be adjudicated as out of network.

 

[ltravisjr]

I would not be surprised if it is adjudicated as out of network. However, it has been very complicated. The insurance company is distributed among different states and the plan is from the state my employer is from while I live in a different state. We researched the providers in the network for the employer’s plan and the doctor’s name and group showed up as in network according to the plan in the state of my employer, but the claim got processed though the insurance office of my home state and for some reason in my own state the provider belt not the group were listed as in network. Apparently the criteria of the insurance office of my home state rules, even though there is no way we could have known since our employer sponsored,plan is through that state. Anyway, the insurance offices of both states went back and forth and the rep came back to us saying if we could show just the doctor as in network via her NPI, all would be good.

What IS simple is that this provider does not practice in any other group. It is not as if she splits time between in and out of network offices. What is the point of her being personally in a network if the benefits of her network status will always be determined by her group’s status?

Through all of this, the customer service rep said we have been doing everything we should be doing or could have known we should do. Now we find that it wasn’t sufficient. Is there any recourse, outside of the insurance company’s own system, that we can take if their internal appeal does not work in our favor?

 

[ltravisjr]

Did you use the in-network VENDOR for Hearing Aids?

The audiologist supplied them. Insurance just got a bill from the office which had the doctor’s name (& NPI which we furnished) on it.

 

[YouGotMyMoney]

The audiologist supplied them. Insurance just got a bill from the office which had the doctor’s name (& NPI which we furnished) on it.

I am assuming you have a Medicare Advantage plan. Most of those plans utilize a 3rd party vendor for hearing aids.

So going to an in-network audiologist to obtain those hearing aides may not be covered because you are not using that 3rd party vendor.

What charges specifically are being denied? The Specialist charges, the charges for the hearing aid?

 

[ltravisjr]

To add to the story, when my wife went in, she inquired about network status and they realized that the first audiologist that was going to serve her was not yet in the network so the other one who already was in the network took her. It seems then that they understand that their contracting arrangements with insurance are based on the individual doctor given that they shuffled them around to make sure she had a doctor that would work for her.

The odd thing was that even though the doctor was in network, she asked my wife to send the claim in because I guess they don’t like the hassle. That is an irregular (maybe illegal?) request so there is no “in network” form for a patient to send in. Therefore, my wife sent in an out of network form but handwrote on it that it is really in network claim.

So with the confusion inherent in this already, we are disadvantaged because normally the provider and insurance company offices hash all this out and its transparent to them. We are somewhat out of the loop of communications and of course don’t have the same expertise, hence my approaching this forum for help understanding.

 

[ltravisjr]

I am assuming you have a Medicare Advantage plan. Most of those plans utilize a 3rd party vendor for hearing aids.

So going to an in-network audiologist to obtain those hearing aides may not be covered because you are not using that 3rd party vendor.

What charges specifically are being denied? The Specialist charges, the charges for the hearing aid?

No, this is a PPO plan from a major insurance company and is part of my employer’s benefit package. The EOB stated the coverage does not provide benefits for these services (010001), and that the amount is over our benefit allowance (010004). What is odd is that my plan (administrated through the insurance office of state of my employer) *does* cover hearing aids, and up to $5000. That seems to conflict with what my plan says. Could it be that the aids are either not covered the same in my home state, where the processing actually takes place?

 

[leevena]

I have read this a few times and am very confused. A few thoughts for you to consider. 1. This situation has many moving parts, and as such it is difficult to communicate in this type of forum, so bear with us. 2. Depending on the situation, your administrator could have a variety of networks from which your employer can choose from. When you go to the search engine you need to select the correct network from which to search. It is possible for a provider to participate in one network, but not another. 3. The issue of the provider showing up in the one state, but not the other makes no sense, something is not right here, I have never heard of this occurring. Criteria does not change by state. Sounds like someone is covering their behind. 4. Contracting can be confusing, it is possible that the provider is in-network, the office is not, and the claim was filed via the office, thus being OON. 5. Your explanation appears to conflict. Early on you stated that the office recognized the provider is OON and switched your wife to an in-network provider. But now that doctor is OON? 6. Is this an OON issue, or over allowable charges issue?

 

[ltravisjr]

leevena and all, thanks for the help so far. Let me see if I can clarify a bit...

I spoke to my wife and found I was mistaken on the published network information. The doctor shows up in-network in both states and the group doesn't. Also, the doctor does not practice in any other office or group and the hearing aid invoice lists her name as the "provider". That said, here is the general sequence of events:

• This year our plan introduced a new hearing aid benefit of up to $5000
• Wife's primary care physician refers her to an audiologist.
• That audiologist was OON so the office let another audiologist there - one who was in network - treat her.
• The office asked her to file the claim herself because its a hassle for them to do it.
• Wife filed the claim but with an OON form since there is no in-network form available to patients. She handwrote that it is really in-network and submitted it with the invoice.
• EOB comes back saying it paid less than $500 and coded that the coverage does not provide benefits for these services and that the amount is over our benefit allowance.
• Wife calls the customer service rep and the rep calls our home state's plan office, who says the provider is OON.
• Wife explains the provider is the doctor herself, and that the doctor is in network and listed as such on the insurance website.
• Rep says to get doctor's NPI to prove it and resubmit the claim for it. Then they will write it off.
• Wife does so and resubmits.
• Insurance rep receives it and says they will expedite a corrected claim.
• After a couple weeks we hear back that it has been determined that the group is out of network and our request will go to their internal appeal system (they did not even acknowledge the doctor's status).

There are two issues here:
1) That the doctor is the provider and has network status and insurance hasn't acknowledged it.

2) The fact that the EOB is coded as not providing the benefit and that charges are over the allowable amount, which seems to disagree with the benefit as described in our plan documents.