Can an "in network" hospital bring in "out of network" physicians who you then have to pay????

[NYC_SKP]

This has to do with ACA covered california Anthem Blue Cross PPO Silver plan.

Just went through two stays at Stanford for treatment of an aneurism and a second stay for infection of the site.

Stanford Hospital is in network, but I have lots of charges not covered by Anthem Blue Cross PPO.

It's hard as hell to get a straight answer from them, their website "explanation of benefits" buttons don't work on my computer and phone calls to live people aren't helping.

For a plan that I thought had $6,350 max out of pocket, I'm learning now that this max only applies to "in network" and there's a different out of pocket for "out of network" that in my case is $10,000.

This seems different from what I thought I was signing up for, which was a $6,350 max annual.

Not it's looking like $16,350, if not more.

Please help if you can.

[elleng]

1. Not sure, SKP, contracts and insurance being what they are,

but there should be something about 'different out of pocket for "out of network"' IF that's the case. Complain, write, appeal!

And if you don't prevail, work out a comfortable arrangement, pay it off over 10, 20, 30 years??? Your brain's certainly worth it!

[NYC_SKP]

2. Thank you!

And I've been told by Anthem people that only those who fight ever get a break.

I'm just not sure if I fight Anthem or Stanford or both, it's pretty labyrinthine-- the insurers and the providers.

Still happy to be alive and happy to be insured, what with easily over $500K in charges, but that is why I have insurance.

I'll keep hammering away at all of them.

[Warpy]

7. If there was no "in network" physician at that hospital who was there and able to handle your case

(and I suspect that is the case), then you are going to have to fight them. And fight them you must. If they can't supply a doc capable of handling your problems from their "stable," it's up to them to provide and pay for a doctor who can handle them.

If yelling long and loud (now that you're better) won't do it, your payment plan will be five bucks a month.

I'm glad you're still with us, no matter how BC/BS tries to fuck you over.

[NYC_SKP]

9. Thanks, Warpy!

I still believe in ACA, and in one's individual responsibility to participate, but the devil's in the details.

Also, some problems in the roll-out, maybe. I hope I have a good case.

[NYC_SKP]

8. ARTICLE: Anthem lists Stanford area doctors as in-network, turns out they are not.

Not sure if this is part of the problem or not.

I have to fight, even though I don't have a lot of energy to do it.

http://sanfrancisco.cbslocal.com/2014/04/21/insurer-admits-nearly-1000-doctors-wrongly-placed-on-covered-california-list/

[elleng]

11. Could be.

Anthem eats it (imo!)

[yeoman6987]

13. That is with all insurance programs from medical to dental

There are different prices for in network and out of network. You will have to stay in network if you want the cap at 6 grand. Unfortunately it is too late for this time, but it will make it easier for you from now on to ensure that you only use in network medical. That is the insurance company making deals with doctors offices and hospitals.

[NYC_SKP]

17. They make exceptions for emergency services, I had a lot of things covered.

But then even those go to your "out of network" deductible and out of pocket. There are two different sets of figures.

In Network Deduct: $2,000
In Network Max OOP: $6,500

Out of Network Deduct: $5,000
Out of Network OOP: $10,000

The games they're playing could cost me $10,000, but both admissions for services were Emergency Room.

When shopping the ACA site, only the in-network figures are compared, the out of network are in the fine print, page 37, I guess.

thanks for the advice and support.

[yeoman6987]

21. I wish you the best of luck

I wrote my post before I read some of the other DUers and they had some great ideas.

[MannyGoldstein]

3. Oh God, I feel for you!

It's not enough to take ill, they need to administer a wallet-ectomy as well.

I don't know what the rules are, but you might want to send a letter to Anthem and Stanford stating (assuming it's the case) that you had no desire to go out of network, don't understand your charges, and won't pay until they give you a detailed explanation of how you incurred an extra $10k in charges without your consent. Send it by registered mail, it might help catch their attention.

They've both got mountains of cash, if you're in the right and complain to the right people (perhaps including the Attorney General), there's a good chance that you'll knock that $10k down by some amount.

Mostly - it's great that you're OK!

[NYC_SKP]

6. Well, they do bring paperwork to read and sign as you're laying on a gurney in the hallway.

In writhing pain and fear.

True, I'm grateful to not be dead, but feel a big fat bait and switch when shopping for insurance and with what the hospital is doing.

I found some news articles about Stanford and Anthem, it was a rocky start between them with ACA.

[MannyGoldstein]

10. That's under duress. What choice did you have?

Good luck!

[NYC_SKP]

12. Thanks. I did a little research.

I really think hospitals need a navigator/assistant before they give you papers to sign.

I was in network, even if not it was an emergency (but that's when out of network deductibles and OOP maximums kick in).

The charges seem to be for individual physicians who "dropped in" while I was under the knife, twice.

I'll fight it, I'll be nice and everything. I'm two hours away but staff is getting to know me on site, in a friendly wat.

Check this out:

http://sanfrancisco.cbslocal.com/2014/04/21/insurer-admits-nearly-1000-doctors-wrongly-placed-on-covered-california-list/

:/

[MannyGoldstein]

19. As a member of the Medico-Industrial complex, I can assure you

that everything involving money and docs is byzantine, ill-defined, and berserk. If you spend some time investigating your situation, it's pretty likely that you'll find some #%^* ups. Once you do, they'll likely start caving if they don't already cave once you get firm with them.

This is exactly why medicine can never be "free" market: when someone has an emergency, they can't shop around. They need help now.

[Brainstormy]

34. It's SUCH a racket

and there's a whole "you scratch my back, I'll scratch yours" thing going on among the doctors. Just Keep Calm and Keep Objecting. When it comes to insurance, only the squeakiest wheels don't get completely greased.

[Hoyt]

4. Also complain to the hospital for not informing you they accept ACA, but don't ride herd on docs.

Not sure there is an absolute prohibition on that, but it ain't the right way to treat patients.

Let us know what happens.

[NYC_SKP]

5. Will do, it takes a shitload of phone calls to get anywhere.

And all the while on home IVs and trying to get better.

[elleng]

14. Rest.

They can wait for the money.

[Hoyt]

26. Good advice. They aren't likely to pressure patient for months, and even then there are limits on

what they can do.

[elleng]

27. Yes and they'll be paid the undisputed amounts initially,

probably won't have a full accounting for months.

[DJ13]

15. With my wife in Stanford for a total of a month in 2012

and getting to know the staff and the organization, I really dont understand why they wouldnt have a doctor in residence in that monstrous hospital that could handle your condition.

That must have been a real serious condition, glad you're better!

[NYC_SKP]

20. Complicating matters, CoveredCalifornia had my correct birthdate, Anthem screwed it up.

And it too about a month before they straightened it up. I still wonder if that error (their error) isn't behind some of these issues.

I think the surgical team was/is great, all the staff are.

I think this is a business office problem, at both organizations.

Thanks!

[Daemonaquila]

23. The short answer is yes, but give 'em hell.

To put this answer into perspective, I'll go back to the early days of HMO hell. Hospitals used to do things like leave a patient on the gurney until a doctor who was a plan participant got there, despite plenty of others being available, because not only would it affect the doc's compensation but the hospital's. People died. One particularly disgusting example happened at a well-reputed teaching hospital in my former community, over a 4th of July weekend. A patient was having a heart attack in ER, but policy was that no doc who wasn't a provider under that HMO should touch him. Call after call was made, but everyone was on vacation, not answering, playing golf, etc. Finally, a doc came in off the links hours too late. It didn't take a lot of these cases before it was mandated that when a patient is in urgent need at the hospital, you take care of that patient and you use whatever doc is available, and the insurer can't refuse to pay just because the doc isn't a participating provider.

So, we fast forward to 2014. The system is still busted, but nobody much cares to fix it because patients are only going broke, not being so rude as to die and wreck the hospital's PR, because of insurance red tape. Many of the docs at a hospital are now contractors, because it's more "cost effective" than hiring them as staff, particularly individual or groups of hospitalists who staff ERs, docs who see patients on the wards instead of their own docs (particularly if they have no primary care doc or they have a doc that doesn't have admitting privileges at that hospital), radiology groups that interpret imaging, etc. Since they aren't hospital staff, their bills are often sent straight to the patient, separate from the hospital's own services. This is why, if you have an appendix out, you may get a hospital bill for ER time and supplies, hospital room, meds and wound care services and supplies, OR services, and so on, but you'll also get separate bills from the group the ER physician belongs to, the surgeon who came in at midnight for the emergency operation, the anaesthesiologist's group, and more.

The hospital doesn't really care if they're in your network or not. It's no skin off their nose. Especially in an emergency, they aren't going to try to find someone who's a participating provider in your plan because... early days of HMOs. There's more liability and bad PR in failing to provide timely care because they're trying to match insurance plans, than in leaving you stuck with a huge bill.

All that being said, you may be in a good position to talk down a bunch of the bill. Hospitals and docs usually are willing to have most of their bills paid without spending a lot of hassle on it, than squeezing out every penny if that will take a lot of time and energy. In some states, you may even have some legal protection. It's worth looking in to. It's amazing what you can get taken off a bill, particularly if you can show that something was unnecessary, not actually provided, bungled, or done for the hospital's convenience rather than your needs.

Here are a couple articles that explains some of it differently than I do, but... same basic idea.

http://fairhealthconsumer.org/reimbursementseries.php?id=40

http://www.nytimes.com/2013/10/19/your-money/out-of-network-not-by-choice-and-facing-huge-health-bills.html?pagewanted=all

[NYC_SKP]

25. thank you for the help and the links.

I'm pooped but will read them tomorrow.

Getting ready for #3 of my daily three times daily home IV injections of antibiotic, their surgery site became infected, that's part of the costs.

[JayhawkSD]

28. Technically, yes but insurance may pay the charge

I had a hospital bull where they outsourced lab work to an "out of network" provider. They billed me for the amount that was not covered dur to it not being "in network" and I simply wrote a brief letter saying that the choice of provider was made by the hospital, not by me; that I had chosen an "in network" hospital and should not be penalized for any choices they made. The insurance company did not argue and voided the charge.

[mopinko]

29. bark up the chain.

a friend of mine used to always say- the clerk is a jerk. by which she didnt mean their personalities, just that it is their job to say no.

copy that newspaper article and ask them why the hell they dont have the docs in their network. and just to be on the safe side, i would get those docs names and just look them up to make sure they actually ARENT in the network.
when they refuse to answer, dont ask to be connected to their super, make them spell out the name, then ask. then look them up and call direct when your call mysteriously cannot go through.

if you are too tired to call and yell at them, i can be your sister from chicago that is gonna straighten it out for you. they dont want to hear from your sister in chicago. but you cant help it. she insists on helping you get well, and she is f'ng sick of money and medicine together.

ftr, i had a small surgery scheduled today at a free standing surg center. in spite of the fact that the doc found a raging bronchitis at my pre-op, they kept insisting that i was still on the schedule until the got the report from the doc. they actually asked the anesthesiologist about it. he seriously insisted that if she cleared me, i was a go.

i put up a facebook post saying- at this point, if you arent worried about me, i'm worried about you.
the resched will NOT be at that center. it will be in the regular damn hospital.
that was just plain greed. so much for docs as gatekeepers for YOU.

[NYC_SKP]

30. Hey sister!

Thanks!



I have a lot of calls to make.....

[mopinko]

31. stbex's secret plan- you dont have to hit anyone with a hammer if you play it right.

just tell them about your lovely hammer.
show them a picture of your shiny, heavy hammer.
bring your lovely hammer to work with you, and leave it on the credenza.
move it to the side of your desk.
polish it.
place it on your desk, in front of the tiny chair.

if it hasnt worked by now, start foaming at the mouth.

if it gets past this, it is best to just retreat.

and call your sister.

[WilliamPitt]

32. This sounds eerily familiar.

"It's hard as hell to get a straight answer from them, their website 'explanation of benefits' buttons don't work on my computer and phone calls to live people aren't helping."

I'm sorry for your troubles. Good luck. If my experience is any metric, you're going to need it.

[NYC_SKP]

36. Thanks! Fortunately, the CoveredCalifornia representative was very kind and helpful!

She acknowledged that they get a lot of this and explained the different steps I should take.

She directed me to the Department of Managed Health Care, and they were also super helpful and will initiate an investigation in 30 days, first I have to file a grievance with Anthem.

So, as ever, the Insurance Companies are the bad players in this, though I'm not thrilled with Stanford for letting "out of network" doctors anywhere near me.

Hoping all in your family are strong and well, Will.

[StatGirl]

33. I saw an article just this morning about a lawsuit against Anthem . . .

. . . for misleading and misinforming their customers. See http://www.mercurynews.com/health/ci_26114686/anthem-blue-cross-accused-fraudulent-enrollment-practices. They are in trouble and they know it.

I echo the advice that the others are giving. Don't pay one dime -- except your emergency treatment co-pay -- until all the paperwork gets sorted out. It will take months. The hospitals are used to this. They'll send you bills every other day. Just put them in a file or notebook, and record them on an Excel spreadsheet if you can. (The only exception to this rule is if you pay in-home care people directly; they deserve prompt payment. It doesn't sound as if you're in this situation, though.)

Try not to stress over it. It's a game that the hospitals and insurance companies are playing, not only with you, but with each other. You are likely to win if you keep talking and writing to the right people -- including the state authorities. Send lots of letters to the hospital, the doctors, the insurance company, and the state insurance people, explaining that you acted in good faith by going to an in-network hospital and didn't consent to be treated by out-of-network providers.

Sending good vibes for a speedy recovery!

[NYC_SKP]

35. Thanks, this is most helpful in building my case.

And staff at CoveredCalifornia acknowledge that there are lot of problems, but she was as kind as could be, and helpful.

She directed me to the Department of Managed Health Care, who were also very helpful and described the process for filing objections and initiating investigations.

[StatGirl]

37. Great!

About the out of network thing, though -- pretty much all hospitals except Kaiser have that problem. They have a list of specialists who are available, and they have no good way of knowing whether any particular specialist is in the network of any particular patient.

So as much as I like bagging on overpaid hospital administrations, I have to admit that their hands are tied on this one. As Daemonaquila pointed out, you don't want patients dying or suffering irreparable damage because they have to wait for an in-network doctor to show up.

So it really is on your insurance company to cover your emergency care, and to recognize that you don't have any choices when you're in that situation, and that's where the focus needs to be.

The real solution to the "everybody has different insurance coverage and different networks and different co-pays and different deductibles and different out of pocket maximums" problem is single-payer. But I don't have to tell you that!