DH is scheduled for surgery in 2 weeks with an up-to-a-week hospital stay for recovery.
Just found out today that the surgeon is out of network. Spending hours on the phone to determine best way forward. Fortunately the hospital and clinic is in-network.
Any suggestions? My blood pressure is definitely rising over this.
I hate the American health care system.
I assume you crunched the numbers to figure out how much this surgeon would cost you. I know we have an OOP maximum, but you have to account for the deductible (which would apply even with an in network doctor) and any co-pays until you hit the OOP limit.
I am not aware of whether you can appeal to the insurance company. Will the doctor reduce their rates in light of this?
I am curious why they didn’t ding you for seeing an out of network doc when you had your original visit(s) with him/her.
No one will tell us how much the charges will be!! And our insurance won’t tell us what the out-of-network dollar amount they will cover.
I think he was seeing someone else and she is being brought in as the surgeon.
Fotrunately, he is in good enough health that he can postpone this until it gets resolved, but he has scheduled his next few months around this date so we really don’t want to.
You are correct that this is a stupid system. So your DH goes, gets evaluated and they decide Dr. X is the best person for his situation. But the insurance dictates whether they pay this doctor. Or you can go with Dr. Z who may not be as good, but is in network.
My son had such a runaround trying to get an HMO referral for a sleep doctor, he had to cancel 2 appointments due to paperwork. The office would not even let us just pay out of pocket for the appointment!
Oh yeah - -we had the same issue with a sleep doctor. We ended up paying out of pocket for an online provider who sent the testing kit immediately, results two days later, and a CPAP machine within a week. the in-network providers all had waitlists of months.
And for my DH, it isn’t even an HMO – we are with a HUGE insurance company in California and almost every MD we’ve seen over decades is contracted with them except for an occasonal naturopath. And our hospital/clinic is in network and is also tops in the area and huge. this is just so unnecessary.
And now of course we will have to confirm anesthesiologist etc is in-network. Good thin this isnt an emergency.
I thought they had made this illegal in California? I know the “surprise! you’re anesthesiologist is out of network” was made illegal, but thought this had applied across the board to surgical teams at in-network facilities?
“Beginning July 1, 2017, California law protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility and receive care from an out-of-network provider without their consent. In this case, the law states that consumers only have to pay their in-network cost sharing. Medical providers are prohibited from sending consumers out-of-network bills when the consumer followed their health insurer’s requirements and received non-emergency services in an in-network facility. Facilities include hospitals, ambulatory surgery centers or other outpatient settings, laboratories, and radiology and imaging centers.”
" What if I want to see a doctor who I know is out-of-network?
If you have a health insurance policy with an out-of-network benefit, such as a PPO, you can choose to go to an out-of-network provider. If you go to an in-network facility and want to see an out-of-network provider, you have to give your permission in writing by signing a form provided by the out-of-network provider at least 24 hours before you receive care. The form must be separate from any other document used to obtain consent for any other part of the care or procedure and should inform you that you can receive care from an in-network provider if you choose. At the time consent is provided, the out-of-network provider shall give the consumer a written estimate of the consumer’s total out-of-pocket cost of care."
Maybe the best course of action is not to ask too many questions prior to surgery.
Unfortunately, I have no helpful information - just another complaint about medical pricing. WHY can’t an office tell you how much a procedure will cost? On my last visit for a specialized test, I had to sign a form that said I would pay for the procedure if Medicare would not. This seems standard although in this case it called out Medicare specifically.
I then asked what the maximum amount might be, before agreeing to be responsible. NO ONE could (or would) tell me - not the MD office or the billing office. This was for a particular procedure - not an unknown or open-ended one. I think I ultimately signed the form, with caveats next to my signature, but no one seemed to care as long as I signed something.
I’m sorry you are in this situation. How ridiculous that they even allowed the surgery to be scheduled with the surgeon in the first place. THAT should be illegal. Consumer’s should NEVER have to deal with this unfair situation. I hope you can resolve it by finding another surgeon, but I would consider filing a complaint to with the state attorney general’s office.
Surely the surgeon will be able to refer you to a colleague who is in-network? This seems like something the docs must deal with multiple times a week.
I wouldn’t go out of network if I had a choice (i.e. not an emergency). I got hit with a 37K bill (hospital, physicians, testing) for a one night emergency stay a few years ago. It took forever for the ER attending, the surgeon, and the anesthesiologist to attest (to the insurance company’s satisfaction) that it was- in fact- an emergency and therefore no time to find in-network providers or get a second opinion, or to determine if an MRI was really necessary.
The surgeon’s office assured me that there was no way the claim would be denied under the circumstances-- but it took months and the phone calls and letters were more stressful than the surgery had been.
So if this is NOT an emergency- ask the surgeon for the best in-network referral…
Update: situation is resolved. Although the surgeon is not in network under her own NPI, apparently she only bills under the hospital’s NPI, and the hospital is in network for us.
This all started because we got a utilization management letter from the insurance company saying she was out of network.
Sigh.
Whenever I have had any surgery, my insurance company has provided the doctors and me with the cost estimate…because my docs expected the copay before the procedure.
Yep. Our office does the financial consultation the day of the surgical consultation which is a few weeks before the surgery. Patient’s sign a financial agreement then. They have a clue. Nothings 100%but we are usually close. Dealing with insurance companies for all has been a pain and getting worse. It’s not about Healthcare anymore. Ugh.
But I came to say and I am glad the OP figured it out but… You need to build some sort of relationship with your doctor /surgeon. You just don’t want someone to show up that you don’t know. For emergency surgery, yes. But not for elective surgery.
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