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Posted 10/30/2019 4:04 PM (GMT 0)
Last year, I had a procedure done at a local hospital. It turns out, the anesthesiologist was out of network. We ended up having to pay a substantial bill out of pocket. Now, Randy is scheduled for an AUS in November. I'm trying to avoid a repeat by asking ahead of time if the anesthesiologist is in network. I have made 6 phone calls, and send 2 emails, but no one seems to be able to tell me who the anesthesiologist might be. It's like it's a state secret. When we were billed for an out of network provider last year the insurance company acted like we were irresponsible for not finding out ahead of time that a provider that we didn't hire was out of network. Now the hospital and surgeons office are acting like we are insane for asking. How does one avoid these surprise costs if/when you can't even find out who might provide services?

Donna.
Posted 10/30/2019 4:40 PM (GMT 0)
Call your insurance company and ask them for a list of anesthesiologists who are in your network. Armed with that information, find one that is accredited at the hospital where the surgery will be performed.. Call him or her and make the arrangements yourself..

It seems to work this way...Once your surgeon books an operating room, the hospital provides an anesthesiologist for the operation..You could take your list of in-network anesthesiologists to the hospitals OR scheduling dept. and ask them to please use an in-network doctor.

Sometimes hospitals have staff anesthesiologists that are paid by the hospital as employees. But it's cheaper for them just to use "independent contractor" doctors who will bill you directly for their services..
Posted 10/30/2019 4:55 PM (GMT 0)
Here's something that might help, and maybe something a lot of us haven't been aware of.

"... give your doctor’s office another call and ask for its tax identification number. When you call your insurance provider, use your doctor’s tax ID number to clarify which medical provider you’re inquiring about and have your plan information handy. (Also) Make sure you ask whether the medical provider is in your network, not just whether the doctor is covered by (your insurance plan)."

That final sentence was also stressed in the article, so something else to check into.

See for details:

https://www.forbes.com/sites/christinalamontagne/2015/02/09/how-can-i-verify-if-a-provider-is-in-my-coverage-network/#3e5c361c2962
Posted 10/30/2019 7:07 PM (GMT 0)
Thanks, guys. I called the surgeon's office and they told me to call the hospital (gave me a number). The hospital told me the surgeon's office hires the anesthesiologist and should be able to give me a name. I called the surgeon's office again, and was told the hospital was wrong. I was then given another number for the hospital. The second person at the hospital told me that the anesthesiologists were "on rotation" and there was no way to find out who it would be until the day of surgery. I called BS. I don't believe for one second that planned surgeries aren't scheduled in advance. I can't even get them to give me the names of the Anesthesiology groups they use. Nobody knows. I have a list of in-network providers, but have no idea if any of them are the one who will be participating in the surgery. Nobody, so far can even tell me if the names I have are groups they use.

My last call was to the patient advocates office. I was told they'd make some calls and get back to me. This, folks, is our free market healthcare system. You can't find out how much it will cost, or even who will be doing it, but you're supposed to make informed choices to get the most for your healthcare dollar. Sorry for the rant.

Donna
Posted 10/30/2019 8:08 PM (GMT 0)
a couple of suggestions

Find out who is the head of Medicine at the Hospital and demand the information; can also go to CEO of the hospital and CC your State's Insurance Commission (state insurance commission is important piece)
I generally stay away from not going to the top right away - you'll save yourself time and frustration. Doubt that the patient advocate office will be able to help much.
Posted 10/30/2019 9:10 PM (GMT 0)
If need be, find another Dr whose staff will be more accomodative. Its outrageous that the Dr, his staff, and the hospital dont give a rats ass if you are billed $5k out of pocket for a Dr that THEY choose.
There was, about a year ago, a 60 minutes episode that highlighted this issue and highlighted the fact that many patients go to the trouble to find a Dr in network only to find out after the surgery that they are billed by an assisting physician that they knew nothing about, who was out of network .

Fight this, and if you need to stay with the same Dr send a certified, return receipt requested, letter to the hospital, stating your coverae with a list of anesthesiologists in network, and stating that you will not be responsible for any Dr chosen by THEM, who is out of network.

Gets me so pissed off.
Posted 10/31/2019 2:13 AM (GMT 0)
I'm very surprised this sort of practice is not regulated. The surgeon would obviously know the patient's insurance policy and the network requirements. If the anesthesiologist was his choice he should know it must be a network doc for insurance reimbursement purposes. Besides, wouldn't the anesthesiologist check the patient's records to ascertain whether he was part of the network? If not, he could decline and advise the administrators to find someone who was, especially for an elective procedure. Personally, I've never heard of a patient choosing an anesthesiologist prior to surgery. I only found out right before I was wheeled into the OR for my morning surgery, as he asked me a few medical questions. It never crossed my mind to confirm he was a network doc. I just assumed it was automatic. Maybe in the future I should think twice. In such a situation I think a fair compromise would be for the out-of-network anesthesiologist who voluntarily took the case to accept whatever the in-network reimbursement rate happened to be as full payment.

I wonder if Medicare has regulations in place to cover such a circumstance, particularly if the patient has an Advantage plan that must use in-network docs? I don't think the system would allow for seniors to get stuck with these surprise bills.
Posted 10/31/2019 12:08 PM (GMT 0)
We ran into something like this with my husband's biopsy - the doctor that did the biopsy was in network, the one that read the biopsy was not in network. You have to question everything even with good insurance like we have.

You don't know what you don't know until you don't know it.

I like the idea of the certified letter but I would send a copy to the surgeon, the hospital and the insurance company stating that all billable staff due to this procedure are required to be in network and will not be paid otherwise. They may still fit someone in that isn't on network (doctor or specialist on rotation) but at least you'll have a starting to point to fight it later on if you choose to.
Posted 10/31/2019 2:11 PM (GMT 0)
Another avenue to try: asking your state insurance department if they can help.

If you google

balance billing protection

(no quotes) the resulting display offers some good reads, including what some of the states are doing, that may help.

Such as:

https://www.commonwealthfund.org/publications/maps-and-interactives/2019/jul/state-balance-billing-protections

and

https://www.commonwealthfund.org/blog/2019/states-are-taking-new-steps-protect-consumers-balance-billing-federal-action-necessary

Unfortunately, what I gathered from even a quick reading of some of these and other articles I found was that this issue of surprise (shocking would be a better word) billing is only now starting to become of interest to the state legislatures, and, as noted, while a few states have already taken some action, the others need to do more.

But at this point it probably wouldn't hurt if you were to call your state insurance office, explain your situation, and ask if they can offer you any remedies.

It would seem like it's worth a try.

State departments of insurance:

https://www.iii.org/services/directory/company-categories/state-insurance-departments

Good luck!
Posted 10/31/2019 4:23 PM (GMT 0)
81GYGY, One of our State Reps just posted on Facebook that "surprise medical bill are putting short-term profit over patient care". I responded and gave a brief summary of our situation, and asked him what he was doing about it. His response was that he proposed a bill 5 years ago, and that it was 'killed' by the Georgia Medical Association. My thought, and my response was that the GMA has zero power to kill legislation unless the law-makers hand them theirs. So far...no response to that.

Georgia is one of those states that has no protection at all for Surprise Billing. Our Insurance commissioner's office advised me that it's up to me to be sure all providers are in-network, but had no idea how I might do that. I intend to write something along the lines of "I specifically decline service from providers who not in network with our insurance plan". The may show us the door, but, HOW in heaven's name are we supposed to know who is in network and out of network if we have no idea who they are?
Posted 10/31/2019 5:39 PM (GMT 0)
Just one more thought.

This sounds like something that ought to be be coverable by a clause in a medical insurance policy.

That is, if all due diligence has been taken by both patient and hospital to insure that a participating physician is in-network, but then, for whatever reason a non-network physician becomes involved, then the relevant clause of the patient's insurance policy kicks in, and the insurance company covers the bill for any non-network services.

The patient, upon receiving the unexpected bill, files a claim with the insurance company, which, as described, then takes care of it.

Only expense to the patient is a slightly higher premium to cover this additional insurance.
Posted 10/31/2019 8:09 PM (GMT 0)
81Gygy, When I had my surgery, the insurance company paid at the 'contract' rate, when we objected. Our local hospital had no anesthesiologists who were in network. Unfortunately, the anesthesiologist would not accept the contract rate and we were stuck with a bill of just over $3,000.00 (for a 20 minute surgery). The insurance company claimed that the amount they paid (around $280) was their in-network price, and the doctors claimed that was not enough. We were stuck in the middle, and stuck paying. When they say they will treat the claim as in-network, that means they'll pay 80% of whatever they would pay an in-network provider. The out-of-network doctor is under no obligation to accept that amount.
Posted 10/31/2019 8:39 PM (GMT 0)
An important issue. Efforts are underway in Congress to help, but we all know how that goes.

Here is a link to an up-to-date summary of the issue that was raised. Unfortunately, I can't provide a solution.
https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/

As an aside, I did have a surprise medical bill a while ago, but the provider was willing to accept as payment the 'insurance rate'.
Posted 10/31/2019 9:30 PM (GMT 0)
Makes it more understandable why Anesthesiologists are one of the highest paid medical specialties. They are 'in the dark', 'behind the scene' crooks. Maddening, and medical 'professionals' turn a blind eye....
Posted 10/31/2019 11:50 PM (GMT 0)
I'm surprised that any Dr. or Hospital would do any type of procedure without checking first to see if the person is covered by some type of insurance. I would definitely if possible look for another Hospital and Dr. you could pay for some motel rooms and travel expenses cheaper then what you got stuck for last time. The other thing I would send 25.00 a month for your last bill and if they don't like that tell them they ain't getting any money!!!! JMHO

Larry
Posted 11/1/2019 12:46 AM (GMT 0)

RandyJoe said...

Georgia is one of those states that has no protection at all for Surprise Billing. Our Insurance commissioner's office advised me that it's up to me to be sure all providers are in-network, but had no idea how I might do that. I intend to write something along the lines of "I specifically decline service from providers who not in network with our insurance plan". The may show us the door, but, HOW in heaven's name are we supposed to know who is in network and out of network if we have no idea who they are?

That should do it.

You'll know who the anesthesiologist is before he's wheeled in. If he's not on your plan, show him the letter. Tell him if he can't find someone on your plan "we'll just reschedule to when you can".

I know that would definitely be a hassle. But it'd get the point across.
Posted 11/1/2019 1:01 AM (GMT 0)
I had a pre-authorized, pre-approved hernia repair at an in-network hospital. They failed to mention that the only anesthesiologist group that the hospital uses is “not in network” Not a bug but a feature of this for-profit ****storm we call healthcare in the ole USA. Went to collections before I knew what it was about, as the EOB stated I didn’t owe anything.
The system is working as designed, a complete financial racket to extort money and to deny coverage. Private equity firms are buying up ER Docs, anesthesiologists, ambulance fleets, medavac copters, etc and preying on the sick and dying. Sorry, out of network, you are responsible for the bill..
We have reached a point where even the insured can’t afford to get sick.
Posted 11/1/2019 5:02 PM (GMT 0)
UPDATE: After 4 days, 11 phone calls, 5 e-mails and uncounted new gray hairs, I finally have an answer. Apparently there is only one anesthesia group at Emory-St. Jospehs. And they are in-network. Or, so I'm told. I've taken names/titles from everyone I've talked to. It was the patient advocate who finally came up with that information, which leads me back to where this started. Why is it so stinkin' hard to get information about medical care prior to having a procedure done?
Posted 11/1/2019 5:13 PM (GMT 0)
RandyJoe,

Crazy, isn't it. This is all on a par with a conversation I had years ago when one of my kids, who was an out of state college student, needed a medical procedure. I was trying to find out if it would be covered. After several iterations of the person on the phone saying in essence, "I don't know", I challenged. The answer I got was: "I don't actually KNOW what is in the contract, so I truly can't say. If I did say that yes it would be covered, then I would lose my job AND be held personally liable if it turns out it isn't covered."

It comes back to: Medicine and medical care is not a commodity like bread or milk. It's something we all need, and it is designed to avoid transparency. And some of the lack of transparency is actually by law.
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