Question
What is the name of your state? Ohio but insurance is out of PA
I have family health coverage through my employer. The premium is taken out of my check every week. The coverage began Jan. 2002.
Every single claim that is submitted to the ins. co. is turned down. For 8 mos. we would get letters concerning 3 doctor visits my middle son had stating that his dr. was not in the plan (the dr. is in the plan). At the same time, the ins co was sending the dr. letters stating that my son wasn't on the plan! After 8 mos of my wife calling, the bills were finally paid.
This goes on with every single bill we have. Another excuse has been that we have another ins. (which we don't). We've gotten that excuse on 4 of the last 5 claims. Each time my wife has to call and tell them we have no other ins. One time, my wife was told that there was a computer error which is putting that on everyone's claims. The next time she was told that wasn't true.
The bill we received today was about an xray I had last month. The xray was read by a doctor at a hospital which is in our plan. Our plan states we are able to go to that hospital for emergencies, outpatient services, or admissions. However, the bill states that the DOCTOR isn't covered. How can the building in which the dr works be covered but not the dr himself? This is the only hospital that dr works at so I'm sure when my wife calls the ins co next week they will "resubmit" it as usual and maybe this time next year it will get paid.
When my wife inquires about filing a complaint with the ins co, she is always told that they don't have a complaint department so she can't file one! Is there anything that I can do to make this co quit jerking everyone around (we are not the only ones this is being done to)? I feel like we should be able to sue them for all the stress they are causing because we are constantly being threatened with being turned into collection agencies because the ins co takes so long to pay.
Answer
I would have someone go over your file and make sure all information is correct and that there isn't anything in it that flags all your claims.
As far as the Doctor not being covered while the hospital is. Well this occurs quite often. However when you have anything done at a facility you should remind them of your coverage and tell them to be sure that anyone getting involved is insurance-covered. Chances are though this will eventually be paid, not lacking all your headaches. I would contact the hospital and tell them it is a bit of neglect on their part to not know this possibility since they are in the business.
What you might want to consider is contacting the insurance regulatory in your state and explain your problems. They should be able to help you out where the insurances non- complaint department hasn't been able to.
Answer
It is entirely possible for a doctor working in a network hospital not to be part of the network themselves. That is because the hospital contract covers only the hospital facilities; the labs, the nursing care, etc. The doctors, however, contract individually with the insurance companies. The hospital does not have the right to force a doctor to join an insurance network that the doctor does not wish to join.