Just got off a very frustrating chat with Anthem Blue Cross. Looking for any advice (or sympathy!!)
I was an inpatient in the hospital a couple of months ago. My cardiologist is associated with the hospital (not sure in what capacity but he was there in scrubs and spends a lot of time there) and stopped by to see me. The condition I was there for was not cardiology-related, but it was good that he was there because I (and my team) did have some cardiology-related questions for him.
The cardiologist is in network. The hospital is in network.
I just got my EOB. It says he is out of network for the hospital address. If the services were in his clinic then he’s in network. The hospital services for my surgery and tons of my care were in network. This particular combo is out of network. Insert expletive of your choice here.
Is this even legit? Can I fight this? Can he re-bill under his clinic address?
It seems to me that this would fall under the federal Surprise Billing Act. You should not be charged. Use those words with someone at the insurance company and see what happens.
I’m going to add that I am unclear what “he stopped by” means. Did the doctors treating you request a consult? Did you call him? Is he friend who saw your name? If the doctors treating you requested a consult I think it would be covered but in the other situations, maybe not.
I wonder if this falls under the surprise billing act.
Seems like it would be
I had a similar issue with BCBS and appealed a bill BCBS denied the appeal. I ended up paying because it was denied and I was afraid of the bill going to collections.
It’s super frustrating. And made me feel very powerless because the system is very opaque
I mean, I was an inpatient recovering from a multi-hour surgery and my cardiologist stops by to ask how I’m doing and I ask about one of my heart meds that they are also giving me in the hospital – I’m supposed to ask if he’s in-network in that particular hospital as I’m still groggy from the anesthesia???
I was wondering the same thing. When I read, “stopped by”, that makes me think that he knew you were there and came by to see if there was anything he could do, chatted for awhile, answered questions, and then sent a bill. Seems someone would have needed to request a consult with him in order to get paid, otherwise, what was he sending a bill for? I hope he didn’t charge very much for stopping by your room for a bit while he was there anyways, if he hadn’t been requested to be there.
I have a call out to his billing department. Should I ask them about not billing since it wasn’t a formal consultation? I haven’t actually gotten the bill yet — just the EOB
I think you need to call this out to his office. That sounds sleazy to me, like they’re trying to scam the insurance company. What, is he charging $200 a minute for stopping by? Definitely tell them that the insurance company is not covering this in network, and you’re not willing to pay this kind of money for him stopping by, unasked.
DH had this happen in an emergency before the new act. The doctor’s office asked for a letter and then reconciled with insurance and never sent additional billing notices. Talk to the Dr office first.
You can fight this and resolve it easily I think.
I was seeing a new doc, old one had retired. My records were transferred over. I had already done my annual exam, and new doc insisted on doing another one. What do I know? I figured there was a reason for it. I was billed full rate for the exam that I hadn’t asked for and hadn’t needed.
A good friend in the insurance industry told me to call the billing dept at the facility and state that I hadn’t asked for the exam, that I would be filing a complaint with DFS, and that I’d be filing a report with the attorney general’s office. The charge was removed without an argument.
My husband had a procedure that was pre approved. For some reason our insurance denied the surgeon and therefore we were also on the hook for the anesthesiologist. It was an exploratory procedure and they found nothing. Which was what we hoped lol. But insurance did pay the hospital.
I appealed the anesthesia group, was denied. Ended up paying because I didn’t know what else to do. I never have received a bill from the surgeon, we wonder if it’s because they know it’s a surprise bill that was pre approved. Maybe we will get a bill in the future but it’s been since January.
I would wait a bit and see if this gets settled. Last year we had some things that were denied but the office resubmitted to insurance and it all worked out in the end. The wheels turn slowly.
The annoying thing is that it’s been recommended that my husband have this procedure in the future. He will probably decline because of this insurance issue
I’ve learned that a lot of times doctors miscode - is that possible ? I’d start with them.
The other question - do you have an out of pocket max that you’ll blow through ? In other words if you have more to do and later it will be free and you were gonna ultimately get there anyway, then it won’t matter.
Don’t know your policy. I know I have a $7k cap. And we will be well over. If you are similar, maybe letting it go won’t matter.
I can only offer sympathy for the hassle and frustration this is causing while you’re recuperating. I had a similar experience years ago and have been expecting that the Surprise Billing Act would prevent such issues. Good luck fighting that bill.
I have 3 suggestions: Is your insurance through your/your spouse’s employer? If so, contact the benefits administrator and politely tell them what happened. Don’t bother with HR- go to the Benefits Administrator. They are the ones who negotiate the contract with BCBS (even if the company is self insured and uses their network/payor system). They don’t like the insurance company mistreating their employees. That could get BCBS to revisit the claim.
Alternatively, talk to your cardiologist, if its someone you have a good relationship with, and/or their billing dept, tell them what happened, and ask them to discount your bill. Its not likely they can/will re-code your visit as a clinic visit since all the rest of your charges being submitted to BCBS make it pretty clear you were an inpatient, and inpatient and outpatient billing codes have a different prefix, IIRC. So your Dr. should not be asked to essentially engage in billing fraud (which is what that could be) but its also quite unlikely he/she knows about your specific insurance plan, and was doing you a courtesy by seeing you in the hospital. If he/she is a nice person and has the authority to write off part of the bill, thats a reasonable request. If the practice is owned by some bigger group or what have you, his hands may be more tied, and that’s where appealing to the billing dept may be more successful. This exact thing happened to my dad when he was in the hospital, but sadly my dad didn’t survive, and the Drs office wrote off the whole charge as a courtesy.
Your final option, if all this fails, is to file a complaint with your state insurance commissioners office, and mention that to BCBS if you can before you do it. Insurance companies don’t like complaints to the state insu commissioner and will sometimes suddenly be reasonable if you mention you feel you have no other choice.
Good luck, and keep us posted. I had an ongoing issue with BCBS a few years back, and I knew I was right (they misprocessed something and when they reprocessed they forgot to apply it to the deductible). It made a very large $$$ difference. They kept denying it after they said they’d reprocess it, and it took literally a year and a half to get fixed. But I knew I was right (I was a provider for BCBS and I know how to read their EOBs), and ultimately, with the help of my DH’s benefits administrator, was able to talk to a supervisor at BCBS and poof immediately get it fixed, But yes, it literally took 18 mos. Most people, like the poster above, fear a blemish on their credit and pay a bill they don’t owe. Insurance companies can be really sleazy. Don’t give up yet. Happy to help you further if I can!
Also, do you have a copy of the medical records of your hospital stay ?
Some records can be seen via online account. Whenever the dr visited or made notes or orders for nursing care, meds, tests, it may be part of your records.
I know, it’s hard to do when you like a doctor. I am not confrontational, and I would probably find a way to explain this pleasantly but succinctly to his office. Maybe ask them if this was miscoded, because that is crazy expensive. Then again, he is obviously the one who told his office to bill insurance for this. Kind of makes you wonder if he looks to see what patients he has at the hospital that day, stops in to say hello, and then charges the insurance company big $$. It would make me want to look over the other bills his office has sent to my insurance, and see if they’re out of line.
I also wonder if it’s one of those deals when in network, he might send the insurance a bill for 2K and they say nope, in network, negotiated rate $450, and that’s the end of it. I would think when his office realizes that they’re not going to get paid that kind of money from you, maybe they’ll just write it off.
Yep, that’s why, if BCBS won’t address it, asking the office to write off the difference so that the total is what they would have gotten if it was an office visit is a reasonable request. If a Dr rounds on their patients, even briefly, when they are hospitalized, yes there should be a chart note but its also not unreasonable to bill ( and some codes are in 15 or 20 min increments, and some include time fir a dictated “report” and some don’t. But again there are severa options to take to reduce the charge. Good luck @MMRose.