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Author Topic: Out of network  (Read 3966 times)

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Offline retroMan

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  • Posts: 45
Out of network
« on: August 11, 2015, 02:02:41 pm »
Can someone advise me?  I bought a PPO plan, urged by the Healthcare Marketplace, that became effective the first of the year.  I went through painstaking effort to select it, and it was a confusing and frustrating process.   

After paying premiums for a couple of months and going through the website conducting doc searches, I started having gastro discomfort early in the year and found a gastroenterologist that also offered to refer me to a good HIV provider.  Although I presented my ID card ahead of time and begged to have my eligibility confirmed to avoid incurring unnecessary expense, I am now stuck with a $3,000.00 bill because of denied claims due to being out of the plan network.

I gave my group number and information over the phone before the appointment, and they asked for it again at the reception desk on the day of the appointment, delaying me for 25 minutes before then allowing me to get vitals done.  I went to these folks because of the plan directory!
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Offline AusShep

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  • Posts: 526
Re: Out of network
« Reply #1 on: August 11, 2015, 06:49:56 pm »
Quote from: retroMan on August 11, 2015, 02:02:41 pm
...I went to these folks because of the plan directory!
I'm confused, they were in the directory for your specific plan but they're still considered out of network?
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Offline retroMan

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Re: Out of network
« Reply #2 on: August 11, 2015, 10:13:50 pm »
Exactly!
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Offline AusShep

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Re: Out of network
« Reply #3 on: August 12, 2015, 12:10:42 am »
I'd appeal the EOB determination, say they were in the directory as an in network provider...
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Offline retroMan

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  • Posts: 45
Re: Out of network
« Reply #4 on: August 12, 2015, 08:30:35 am »
So direct to the insurance company, not the clinic that first accepted the card?
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Offline AusShep

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  • Posts: 526
Re: Out of network
« Reply #5 on: August 12, 2015, 08:26:05 pm »
Quote from: retroMan on August 12, 2015, 08:30:35 am
So direct to the insurance company, not the clinic that first accepted the card?

Remember you may have a deductible to meet before your plan pays.

You should get an explanation of benefits (EOB) from your insurance company saying the claim was denied for being out of network.  There will be instructions on it for how to appeal.

If it is just a bill from the Dr., call them and  have them submit the claim to your insurance provider.  It's a bit messed up as far as the "bill" rate vs. the approved/negotiated contract rate.  I had a colonoscopy from a GI last month, I think the bill was around 2k for the procedure (I've seen much higher bills from colorectal surgeons), but my insurance rate was about $500, plus the office visit and biopsy fee amounts, and I didn't have to pay anything.
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Offline retroMan

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  • Posts: 45
Re: Out of network
« Reply #6 on: August 12, 2015, 09:02:54 pm »
I had a colonoscopy last year and was erroneouslying billed $2100.00 for that. It took months to clear that up.  Just to have this issue now! 

Thanks for your advice.  Ill review the EOB.
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