Hospital billed out of network, treats it in-network on their side (medical, plan)

[janejanejanejanejane]

Anyone have experience in this? We asked the doctor before the procedure if everything was covered under Aetna and they said yes. Low and behold, the hospital and anesthesia is not in-network.
Sure, it's our responsibility to check on these things, but when we are told yes and don't know to dig further, it's not cool.

Has anyone dealt with trying to lower the bills from these places once they process it as if it is "in network" even though it's really not?

[golfgal]

Originally Posted by janejanejanejanejane

Anyone have experience in this? We asked the doctor before the procedure if everything was covered under Aetna and they said yes. Low and behold, the hospital and anesthesia is not in-network.
Sure, it's our responsibility to check on these things, but when we are told yes and don't know to dig further, it's not cool.

Has anyone dealt with trying to lower the bills from these places once they process it as if it is "in network" even though it's really not?

Honestly, asking your dr if something is in network is like asking you mechanic to fix your washing machine....there are 1000's of health plans out there, even every Aetna plan is different and may have a different network. ALWAYS check to see if a provider is in network. The only way to check that is to check with the insurance person at the provider or call your insurance company. Even calling your insurance company sometimes isn't enough because a provider within a clinic or whatever might have a separate contract so your best resource is the person that does the insurance billing for that provider.

You can try checking with Aetna to see if they will cover it in network but don't count on it.

[texdav]

Originally Posted by janejanejanejanejane

Anyone have experience in this? We asked the doctor before the procedure if everything was covered under Aetna and they said yes. Low and behold, the hospital and anesthesia is not in-network.
Sure, it's our responsibility to check on these things, but when we are told yes and don't know to dig further, it's not cool.

Has anyone dealt with trying to lower the bills from these places once they process it as if it is "in network" even though it's really not?

I always call when possible the insurance to check and check network every once in a while on hospital and services they use in case of emergency.My insurance advises to always call before a elective hospital stay to get information.

[Travelassie]

I don't know if this is a similar situation as what you're talking about, but we found that several of the "in network" hospitals in Tampa,Florida signed agreements with out-of network (in this case it was Blue Cross/Blue Shield) doctors who provided services within those hospitals ( ie, emergency surgeons, anesthesiologists) for those docs to accept the payments from the insurance companies, and any applicable deductible or co-pay from the patient as payment in full. In my experience, the insurance paid those doctors their out-of network fee- I don't think it was any less than what they'd pay an in-network provider, and we paid the copays. These doctors could have charged us the difference between their entire bill and what they were reimbursed, but according to the agreement with the hospitals, they did not.

[SJCPHL]

This is nonsense but, unfortunately, common nonsense.

Do you have out-of-network benefits -- ie, do you have a PPO or POS plan? If you do, you'll likely be stuck paying the balance. If you have no out-of-network benefits, the practice will be more likely to work with you, especially if you say things like, "I'm not sure I can really pay this bill." Every practice is different, but no one on CD will know what this practice does until you call. You get more flies with sugar than you do with vinegar, so be nice. A sympathetic biller can help you out a lot in this situation.

Call your insurance company as well. Unfortunately, you'd probably have a better case if you were dealing with an emergency surgery instead of a routine, scheduled one.

Make sure the doctor performing the procedure is aware of this. He, and especially his office staff, should know if something like routine anesthesia is in or out of network. I work for a medical group I can't stand when office staff is clueless about insurance. Aren't these people interested in how we get paid.

[texdav]

The insurance may pay in network but the hospital and providers have no contract in agreeing to accept a lessor amount. its no ski off the insurance if they pay in network to them or to a in network; same cost.

[CaroleF]

I had this problem in spades recently. I had an emergency trip to the hospital in January. I had to have my gallbladder out but had the complications of sepsis that had to be controlled first. I was in hospital for two weeks. The hospital was in network with United Healthcare. My gallbladder surgeon was in network but his assistant, chosen by him and without my having any say was out of network. The assistant surgeon billed $5000 to United, who paid him the in-netwrok fee of about $90. Fortunately, his office is appealing against this decision and have told me that if United doesn't pay, they will write off the glance and I will not be responsible for it because they know I didn't choose this doctor. United is saying that according to their contract with me, I am responsible for out of network expenses and it doesn't matter if I had control over whether the provider was out of network or not. Good luck to the OP. Call the provider. I have found them very kind and helpful. Ask for a discount.