Question
What is the name of your state? Georgia
Hi,
I'm going out on a limb that someone may have some helpful advice. I had $5,000 worth of medical tests done. The Doctors office told me that they took my insurance (yes, I now know I should have checked with my insurance ahead of time). It wasn't until after the tests were done (they had my insurance card and info for three weeks by this time) that they told me that they were out of network and handed me the bill. Am I legally obligated to pay this? Do they share some responsibility in this? More importantly what recourse do I have if they refuse to compromise on the bill?
Any help would be tremendously appreciated. I simply don't have the ability to pay this.
Answer
Yes, you are legally responsible for payment. If you have insurance, it's your responsibility to check your policy or call the insurer to determine if any particular service/provider will be covered. It's not the responsibility of the provider to do so. In fact, providers only bill insurers directly as a courtesy to you. They are not required to do so; legally, they are free to give you a bill and demand payment from you directly, whether you have insurance or not (except for Medicare/Medicaid).
Are you sure your policy doesn't allow you to send in a claim yourself and recoup some money, even if your provider was out of network?
As for payment, call the provider's billing reps and ask to set up a payment plan. If they're not willing to do that, get a loan or use credit cards. Delaying is just going to ruin your credit rating.
Answer
Most people in this situation, even the ones who ask in advance, ask the wrong question. What you should be asking is, "do you participate in my PPO network"? Some carriers offer more than one PPO network and the plan you signed on for may cover some providers in one network that are not covered in another network.
If you chose the rates for network "A" and your provider participates in network "B" but not "A" you have generated an out of network claim and will be penalized.
You may get the carrier to waive any penalties for out of network claims but the payment they make may still fall short of what is needed to satisfy the provider.
For what its worth, most labs dont participate in any network, do discounts are not available. Labs are among the growing list of hidden providers.
Answer
Thanks for the info so far. Would i have any leg to stand on to challenge these charges in small claims court. Basis of this argument being that I took it on good faith that they accepted my insurance because they said they did.
Could I argue that they share responsibility for giving me false info. I'm looking for anything here.
Answer
No you don't have a leg to stand on.
It is ultimately your responsibilty to make sure the services rendered are paid for.
It is very true that providers bill as a courtesy - they get their money faster - however there are offices that don't so you get the bill and it's up to you to argue with your insurance .....
that is just the way it is in this wonderful world of HMO's
Answer
Am I legally obligated to pay this? Yes
Do they share some responsibility in this? No.
More importantly what recourse do I have if they refuse to compromise on the bill? None.
Answer
Would i have any leg to stand on to challenge these charges in small claims court.
Again, it's not your provider's responsibility to answer questions about YOUR insurance plan or to answer them correctly. You are responsible for finding out which provider is covered. If you don't have a plan booklet listing all of the network providers, then you should have called your insurance company to check.
Healthcare providers' responsibility is to deliver health services. They cannot possibly be held responsible for knowing the ins and outs of millions of different health insurance plans and educating patients about those policies.
Answer
I want to try to clarify a little terminology. It seems to me the poster believes that by "accepting my insurance", this would mean that whatever his insurer pays, the provider will accept as payment in full. "Accepting" a particular insurance simply means that the provider is accepting "assignment of benefits" from that insurer, whatever that benefit may be--in whole or in part. Any amount left owing is the responsibility of the insured / plan participant. Also, a provider may "accept" a particular insurance, but that does not necessarily mean the provider is a "network" provider. If / when benefits are paid out-of-network, that usually means a reduction in benefit or in some cases (especially HMOs), no benefit. So, the provider that "accepts" that insurance will accept that payment (or none) with the understanding that the balance due is payable by the insured. Otherwise, if a provider does not "accept" the insurance, they will require the entire amount up front prior to rendering the service. I hope that helps some. lkc15507
Answer
Just an addition. Although I completely agree that providers cannot accurately answer insurance plan questions, I disagree that they are the completely hapless individuals they are sometimes made out to be. The providers routinely question the insurer about a participants benefits prior to providing the service. Quite often in their endevor to acquire new patients, providers will mislead you into thinking your coverage is better than it is. They can only do that if your own knowledge of your insurance plan is lacking. So, in terms of how much you ultimately pay--always question the insurer, not the provider. Believe me, every insurer knows every jot and jittle of every contract they have in place. Learn to ask specific questions regarding network and out-of-network benefits.