Insurance In Network/Out of Network Scam

by Francois 10 Replies latest jw friends

• 

  Francois

  I was just reading Princess' Sam Goody story and since I'm going through something similiar that might affect some of you as well, I thought to throw in my usual two cents worth.

  I recently had a sleep study. Yep. Sleep Apnea. Really bad sleep apnea. The doctor sent me to a durable medical supplies company here in town for a CPAP machine. I asked them if they were in my insurance network and gave them my insurance card. They came back during the CPAP training and said, "Yes, we're in your network."

  They weren't. How do I know? I was billed by this company as an out of network provider and was being billed for a) out of network deductible, b) balance billing on the entire outstanding balance $652.46.

  I went through the roof.

  To make a long story miserable, I took the machine back. The business owner said, "I still expect payment of the balance." I said, "Tell you what, you shit in your left hand, and hope I'm gonna pay you in your right hand and see which gets full first." And waltzed out.

  Made call to the business manager of the pulmonary practice that sent me to this company and told them what had happened. They said, "No way we're going to sit by and watch them try to force you to pay this. You forget about it. I'll call that company tomorrow. We send them lots of business and we'll make it clear we don't appreciate the scam they tried to run on you. This is the second time they've done this in two weeks."

  Point is, many people won't fight something like this. You should. No matter how much some company makes you feel like it's your responsibility (like my insurance carrier tried to do in this case), nothing beats intra-business politics and pressure.

  And the practice sent me to a different company that IS in my network.

  The issue here is the same as dealing with the JW elders: You can't be walked on if you refuse to lay down first. Don't take it. Fight back. Shoot first. Ask questions later.

  francois
• 

  teenyuck

  Oh the stories...

  I worked for a huge medical insurance company. One of the problems was contracts with providers (either docs or DME <Durable Medical Equipment>). The contract may have expired on May 1. Doc checks his records and shows the DME is in-network on April 15. You go to DME on May 3. DME might not even know their contract expired (honest) and say yes, we are in your network. (Many of these companies are huge off shoots of other major companies and info flows slowly).

  We get a call on May 2, from you, checking if XYZ DME company is in-network. Yes it is. We still show a valid contract and they are in-network.

  Three weeks later you call saying no they are not. We check again, read the notes we told you and say "Yes, we did tell you that, however, their contract expired on May 1 and now they are out of network.

  What am I to do? We tell you to take it back or check with a manager if we will cover the cost because we did screw up and tell you the wrong info. This is rare.

  Bottom line on your medical insurance. Fight every bill they tell you is not covered. Our training was to decline the claim the first 2-3 times. Sooner or later the client (you) gives up and pays. Insurance company saves money. It did not matter if it was a legit claim or a bad one. Deny anyway. Insurance cos have a certain # of days to pay a claim, so why pay on the first attempt?

  I ended up getting down graded on my reviews because I refused to deny claims. I would put them through when it was clear that we should pay. However, the next person on the insurance assembly line could deny the claim. It had to be approved by a manager (they were anal) and many times my claims got denied because the client had not called about it 2-3 times previously.

  I ended up quitting after 9 months. Dirty business.
• 

  Francois

  Your response to that kind of pressure from your boss/company is testimony to your sense of personal honor.

  THEREFORE YOU GET:

  ONE GREAT BIG ATTABOY/GIRL!

  francois
• 

  teenyuck

  Aw, thanks Frank. I really hate to see an average Joe (all of us) taken advantage of. The insurance stuff really burned me. The managers had been doing it so long they failed to see how they put their ethics on the line by denying valid claims.

  I am glad I am out.
• 

  xjw_b12

  Francois. I do hope you now have a CPAP. They're lifesavers .
• 

  Sara Annie

  Francois-

  Your story reminded me of the time my husband did an overnight sleep study so that his physician could get an accurate read of how his snoring affecting his sleep patterns, and possibly diagnose him with sleep apnea.

  My husband was so uncomfortable the entire night that he barely slept at all, he got up three times to use the bathroom and needed to be unhooked from all of the sensors, and came home so surly about the entire experience that he was swearing that the snoring and poor nights of sleep were preferable to going through the hell of another sleep study. When his Dr. received the diagnosis, we all had a good laugh: Insomnia. Now, everytime I tell my husband he's snoring, he retorts with a sarcastic "I'm sorry, honey. It's my insomnia..."

  Good for you for fighting the charge. I don't put up with crap from anyone when the charge isn't warranted, no matter what the situation. Eventually, if you keep requesting one level higher in the decision making process, you get exactly what you want. Squeaky wheel and all...
• 

  Francois

  Sara, I hope your husband can get a CPAP. Without one chances are increased for stroke, heart attack, and all sorts of other bad things. I only stayed in my sleep study two hours. I went in, got wired up, took a xanax, went to sleep, woke up two hours later and demanded that the test end. It did.

  However, I was diagnosed from two hours of data and yes (xjw) I do have my CPAP machine now. It's smaller than a shoe box, it makes zero noise, and has a new type mask that doesn't make me feel like I've got the face hugger from Alien on my kisser. I love it.

  francois
• 

  Sara Annie

  Francois-

  Sara, I hope your husband can get a CPAP. Without one chances are increased for stroke, heart attack, and all sorts of other bad things.

  We actually just discussed his doing another sleep study to see if the CPAP was appropriate for him. He turned 40 this past year, and I'm concerned about all of the conditions you listed. He's finally forgotten the annoyance from the last time enough to think about trying it again. And the machine he'd be using would be much less bulky that the previous alternative. I'm going to have another go at him about exploring the possiblity again, on your recommendation.
• 

  LDH

  Hey Francois (and everyone else)

  I want to give you some input on this situation, that I hope will clarify things for you.

  Providers/Insurance companies drop each other and get back together more often than I change my underwear.

  Contracts are written differently for different types of plans. HMO contracts stipulate that your PRIMARY CARE PHYSICIAN is responsible for referring you to a network provider. This is a responsibility their office takes on as a part of their capitation payment. (Don't ask, I don't want to get into Capitated vs. Non-Capped HMO PCPs, LOL)

  PPO/POS contracts stipulate that YOU are responsible for using a network provider. What this means is that you need to call your Customer Service number, get the NAME of the person who told you a certain provider is in network for use on a certain day, and proceed as necessary.

  The absolute WORST case scenario is to ask the third-party provider's office (especially DME type providers) because you are usually dealing with a low-level clerk type.

  I don't know *who* teenyuck was working for; insurance companies are reimbursed at higher levels the fewer times they have to process claims for a certain group. (Performance Targets, and Medical Cost Ratios, to name two reasons.) It costs about $9 every time a claim is reprocessed; it is to the advantage of a carrier to process thier claim correctly the first time.

  You can always appeal a claim decision, but doing so without pertinent information such as names and dates is very difficult. We keep files with this type of information in it.

  FYI, should you be under the care of a network physician for treatment of a chronic/sudden onset disease and that physician decides to terminate their contract with said carrier, you have full right to ask for Transition of Treatment Provision.

  I do know what I'm talking about; I coordinate Broker services for a major carrier.

  Hope this helps.
• 

  LDH

  PS, if you are in an HMO type plan and your physician's office referred you to a non-network provider, you may want to *subtly hint* that you will need to contact provider relations at your insurance carrier.

  If your HMO PCP isn't doing their job, they will be financially penalized (as they should be.)

  Lisa