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Q: Health insurance dispute ( No Answer,   4 Comments )
Question  
Subject: Health insurance dispute
Category: Health
Asked by: brianmcg-ga
List Price: $5.00
Posted: 27 Oct 2005 10:47 PDT
Expires: 26 Nov 2005 09:47 PST
Question ID: 585703
My wife and I are having a dispute with our health insurance company
regarding surgery that my wife had this past summer. The insurance
company is only paying for approximately 1/3 of the anasthesiologist's
bill, and we are being invoiced by the hospital for over $2,500. After
many phone calls, I found out that the reason why was because the
doctor and/or the hospital chose an anastehsiologist that was out of
network. Of course, we had no input into this decision and were never
told ahead of time that this may happen. The insurance company isn't
budging and the hospital hasn't been any help. Is there anything I can
do to fight this? If I do not pay this invoice, what will happen?
Answer  
There is no answer at this time.

Comments  
Subject: Re: Health insurance dispute
From: charliebabbage-ga on 27 Oct 2005 16:05 PDT
 
I assume that you live in the US.  In the UK we have the Insurance
Ombudsman Bureau which will independently adjuticate in disputes
between policyholders and insurance companies.  Do you have anything
similar in the US?

If not, you could consider suing the insurer but their policy
conditions will probably prevent you being successful.  If you refuse
to pay the hospital, ultimately they could sue you for the full amount
they are claiming.
Subject: Re: Health insurance dispute
From: mellowyellow-ga on 28 Oct 2005 21:16 PDT
 
What state do you live in?  Who is the insurer?  Do you have all the
documents you signed for the admission and procedure?
Subject: Re: Health insurance dispute
From: dickg-ga on 29 Oct 2005 09:53 PDT
 
I recently had a somewhat similar occurrence--but double the amount in
which you owe--you have an accurate picture. This is what I know and
it may be redundant--

-Networked providers are health care professionals who agree to bill
the insurer at a set amount. When one goes outside that network--there
is no implied cost containment. On the good side this helps to keep
costs down.

-First --Check your policy--was the surgery outpatient or inpatient?
My wife was in the hospital for three days and it was considered
outpatient surgery. Different sets or rules may apply here. Make sure
that this is not a "preauthorization" problem as opposed to a "out of
network" problem. These can be different problems with different
solutions.
-Second-The Insurer will be the unlikely party to give any here. If
you read your policy there will be a disclaimer about going outside of
the network. You are legally responsible for the unpaid balance.

-Third--Go to your Dr/Hospital. Or more specifically the business
agent/accounts manager who handles the insurance--explain the problem.
Keep coming back to them. Why are they charging more than the network
approved fees?? Tell them you can't afford these costs. Ask them if
they can offer you a compromise. Your hammer here is if you default on
this they get nothing. But you are responsible for this cost and they
could damage your credit. Be assertive, persistent without being
antagonistic. Tell them that you want to do the right thing but this
is just too much money.

-Four-Go to you Insurance company--get the names of a few network
medical providers. Call their business manager up and explain the
situation and ask them what they would charge for this procedure. Are
the network fees that the Insurer is allowing truly inline with what
they say they will pay??? If there are significant difference see pt.
five, six

-five-Get your insurance agent involved. They are a resource here. See
if they can offer any help. They might be able to help you with pt.
four.

-six-Every state has an state insurance board but I don't think they
will be much help since this is not a case of fraudlent practice on
the insurer's part. unless pt. four shows some discrepancy.

-seven-As a court of last resort--look at the arbitration clause in
your policy. It would require a lawyer and you would have to have
grounds to be successful in this but it is a possibility esp. if the
numbers don't add up as per pt.four.

In summary--your best chance for successful resolution is pt. three.
Be persistent but polite. I had a buddy that was told that he owed
$1,700  afterthe Insurer paid their part. He went back to the Dr.s
office and they forgave all but $100 but he had to be persistence.

-Good luck- DickG
Subject: Re: Health insurance dispute
From: candiebar-ga on 22 Nov 2005 13:16 PST
 
Well if I were you I would star looking for an attorney. My husband &
I are going threw something similar. The clinic has filled a judgement
against us and the courts are now garnishing his wages. Even after my
husbands employer sent a letter to the insurance telling them to pay
they refuse. We have secured an attorney and he has sent a letter
demanding payment with in 15 days or we will be pressing charges. We
will see how it goes.

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