Urgent : Out of Network Medical Bills

[rickrohan]

Hi

I booked an appointment for a doctor through zocdoc.com and I uploaded my insurance card. While booking an appointment, my insurance was being shown as accepted insurance by the doctor.

I went at doctors facility and asked them again if they are in network of my insurance and they said yes and charged me $25 co pay.


Now claim is processed by the insurance provider and it says doctor is not in the network and whole amount I need to pay which is around $3600.

Could you please tell me what are the options I have.


Thanks in advance.

 

[adjusterjack]

Sorry, none.

Always rely on the insurance company to tell you if a doctor is in network.

In fact, I'll bet your insurance plan documents tell you that.

Never rely on the doctor's office staff. They just can't keep track of every insurance company.

Your insurance company may even have an online directory.

Another thing. If you ever have to have surgery make sure all the doctors and the hospital are listed with the insurance company as being in network. Sometimes the surgeon is in network but maybe the assistant surgeon or the anesthesiologist is not. They are all in business for themselves and bill from different places.

 

[Josh]

I have to disagree with Jack. It May have been a billing mistake. More importantly ,If you asked the doctor before they took your copay then that should be their fault. I would definitely start with the billing office and emphasize that the office already said they took your insurance. The copay thing should be working in your favor too.

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One other thing, the docs office should verify coverage at the time of service. Provider websites are frequently incorrect and easy to mix up what plans cover which doctors, even within the same carrier. Sounds like you did do the right thing.

 

[GreenSky]

Virtually all doctors will accept insurance. Only in-network doctors are required to only charge the allowable from the company.

While it may be too late in this case, the question to ask is "Are you in my network?". It's an expensive lesson that many of us (myself included) learned the hard way.

Rick

 

[LostDollar]

I think the first thing to do would be to carefully examine the insurance carrier's EOB for the service(s) provided and the reasons for denial. If it truly is out of network provider, then I think the next step would be to visit with some combination of the provider's billing employee and the insurance carrier's customer service department and see if the provider has some other in network name under which the service should be billed.

I can no longer recall specific details, but I had a case with a local physical therapy organization where claims were denied until I could get the provider to submit a billing under the same name their group was carried under in the insurance carrier's records.

The EOB is the controlling document and the provider will continue to try to collect from you until or unless you can get the EOB changed.

That is my experience as a consumer over the last five years at any rate.

 

[junkman]

Hi

I booked an appointment for a doctor through zocdoc.com and I uploaded my insurance card. While booking an appointment, my insurance was being shown as accepted insurance by the doctor.

I went at doctors facility and asked them again if they are in network of my insurance and they said yes and charged me $25 co pay.


Now claim is processed by the insurance provider and it says doctor is not in the network and whole amount I need to pay which is around $3600.

Could you please tell me what are the options I have.


Thanks in advance.

Play hardball with the Doc. You asked whether they were in network. They can sue you or work something else out. Give them a choice. Also, some Docs operate under several tax IDs and network is determined by tax ID.

If this is a large group with some clout, the carrier may be willing to have the claim paid in-network if the provider will agree to that level of reimbursement. I've worked that option several times for clients where I was the agent. The insured was usually someone the employer liked and they were willing to put in a little extra effort.