I was surprised when I read something in the 'HEAL' magazine about the cost of treatment and it mentioned that you may be billed the difference for some treatments as out of network while you are in an IN NETWORK facility and thus have to pay at a higher bill.

While this IS true, I have found that it is often caused by the pathologist/lab/anesthogist/rad/,etc. bill arriving before the facility bill, but even if that is not the cause, if I call the insurance company once the facility bill is in, they will adjust it back to IN NETWORK and reprocess. I have never had to pay the difference for an OUT OF NETWORK charge when I was at an IN NETWORK facility as the article indicates. This has worked for me at both CIGNA and AETNA and I imagine is true with other major insurers.

If the insurance company refuses to adjust, I would ask the facility to write it off. You have no control over who the facility used to process/read the whatever, so unless you were OUT of NETWORK to begin with, I don't think you need pay the difference.

It works for me, give it a try.

Take care,
Eileen

What do you mean by out of network? I have never seen that terminology on any of my bills.

So you are saying that your in network doctor or hospital chose an out of network doctor to do something... And that this can, obviously, cause trouble with insurance...

I have not encountered that, but then Montgomery is small and we have BCBS of AL and like everybody takes it here and throughout the state.

Just faced this situation this week....we are being billed for a radiology reading done at an in-network facility but the reading cost has been denied. Aetna has always caught it before and sent a letter stating that we were not responsible. The local hospital tries it all the time..billing for out of network docs or procedures that should be included in the agreed upon fee.

I always handle the insurance stuff..make the phone calls and such. I have talked with Aetna over the course of Bill's illness several times but when I called this week, I was informed that Bill's account was restricted and that he requested it. WHAT????? Believe me, he would in no way want to restrict me from handling insurance matters...he is allergic to it! I was so aggravated..needing to get the billing matter handled and they wouldn't talk to me. We have to now wait for the form (that we have already signed once) to get here..have Bill sign it and wait for them to process it. GRRRRRRR!

Depending on your policy, a provider/doctor is IN NETWORK if he has a contract with that insurance company and agrees to accept whatever $$$ the insurance contract allows for the bill and not bill you for the difference between the allowed amount and his amount. You are only responsible for the amount between the ALLOWED amount and what the insurance paid. An OUT OF NETWORK doctor can bill for the difference between the allowed amount and what he charges.

On my current policy, charges that are not covered at 100%, are covered either at 90% if IN NETWORK, or 70% OUT OF NETWORK. The other policy available at my company pays 80% or 60%. If for instance you go for a chest Xray at an IN NETWORK facility and they have a OUT OF NETWORK radiologist read it, it will be paid at the OUT OF NETWORK rate. Since you has no control as to who read the film, the insurance will normally reprocess this as IN NETWORK and pay the radiologist the higher rate. You should not be responsible for the difference betweeen the two rates, only the amount above the IN NETWORK rate when at an IN NETWORK facility. A telephone call to the insurance company is usually all it takes to get it reprocessed correctly. If your policy doesn't differentiate this way, you don't have to worry about it.

Hope that explains it better.

Eileen

Love those HIPPA rules don't we. I wonder how many trees that ruling has cost. Zerox it this time so you can fax it back to them when they lose it gain.

Take care,
Eileen

Michelle,

Why wouldn't they fax or e it to you instead of snail mail?

Eileen,

Thanks for the response. Either I haven't had that issue or my ins co caught it but at least I'll understand the charge if I ever see in the future.