Question
From California. Had minor elective surgery done by a doctor affiliated with and with privileges at my HMO at his own surgery center. All pre surgery labs and prescriptions requested by him were accepted, filled and preformed at my HMO. During the surgery he removed a small mole. Unbeknown to me he had the specimen sent to a lab not affiliated with my HMO. I don't know why he did not use my HMO's lab for post surgery work, I certainly did not authorized it. Now he refuses to have anything to do with the bills I am getting from his lab. I personally requested this lab to bill my insurance and provided my insurance information, however my insurance company denied on the grounds ..."we are unable to process your claim based on the information available"...
Am I responsible for bills that were not authorized by me? if so do I have a recourse against this doctor who obligated me to $200 of unexpected fees ? Since he sent the specimen to this lab and they accepted it without my signature or any authorization isn't he responsible for the bill? Is my HMO lax and unwilling to pay, are they even responsible? What can I do?
I will be grateful for any advice and help .
Answer
Whether or not your doctor has any responsibility depends in part on your insurance contract. IF the contract puts the responsibility for making sure that ALL secondary providers are in network on the doctor, then you MAY be able to hold him responsible. However, if the contract does not SPECIFICALLY place that responsibility on the doctor's shoulders, you cannot.
Just as an FYI, most if not all insurance carriers have more than one network. It is impossible for any provider to tell with 100% certainty, solely by who your insurance carrier is, which are in and out of network labs, clinics, hospitals or even other doctors.
You are ultimately responsible for all bills incurred in your care, regardless of whether you "authorized" them or not. Your signature is not required.
Answer
Thank you cbg for the information.
I notice that you are with HR. Does it make any difference that I pay for my own health insurance? I am not getting it through an employer. The HMO is Kaiser Permanente, are you familiar with it's provisions?, they are only in few states. As soon as I got your reply I did call and requested Evidence of Coverage.
During the conversation I also received a hesitant, "...umm, hmm, he is not exactly with us, he gets referals, occasionally..." so consequently I asked, "if he is not with you, what about the prescriptions and lab work requested by him and accepted by you?" I did not get a reply. Something seems fishy here, to me.
I do not understand "You are ultimately responsible for bills incurred in your care, regardless...", if this was a life threatening situation, if he opened me up and found potentially cancerous cells then it would be right, all I had was a small mole on the nose! He made the mistake by sending the specimen to the wrong lab, time was not of the essence. Surely there is a way to right this?
Answer
For something like this, no, it does not matter that this is individual insurance rather than group insurance through your employer. I have a very slight familiarity with Kaiser; they are not in my state but one of my clients has a presence in a state where they are located, and I have investigated them with an eye towards buying a policy through them for his employees in that area. Their reputation, as far as I have been able to tell both through my own research and through my HR compatriots in regions where they are, is good.
The fact that you have insurance does not mean that if the insurance does not pay, you don't have to. The doctors, laboratories, hospitals, clinics etc. that provide care to you, do not have to write off the bills if the insurance doesn't pay. That's what I mean by, you have the ultimate responsibility. YOU received the medical care. The laboratory provided YOU a service. The fact that a third party (your insurance carrier) has agreed to provide payment for these services under some circumstances does not mean that any bills they do not pay are invalid. YOU still must pay for any bills that are not covered by the insurance contract.
If you can convince your doctor that he should pay the lab bill, fine. But the law is not going to force him to do it; nor is the law going to force the lab to write off the bill so that you do not have to pay it. Legally that bill is your responsibility.