Health Insurance Question - Round Rock,TX

THere was a Wall Street Journal article last week that talked about this exact problem. I have looked online and can't locate it, but maybe you could check the library. It was a big article on the back of one of the major sections. My recollection was that you are just out of luck. The doctor is considered to work out of the hospital and it is like a facilities charge. So, technically it is a "coding issue" but one that is not in error. WSJ said that it is buyer beware, hardly a comforting thought. The woman that works for the billing dept was dead-on. Protesting doesn't hurt, but it probably won't help. Sorry, and good luck.

This happened to me once as well. It was weird, b/c we had been to several appts. and they had all been billed as normal office visits, and the insurance paid for them as such. Then suddenly we had a visit that the insurance said had to come out of our deductible b/c it was at an 'outpatient clinic.' I phoned the doctor's office and spoke to the person in the billing dept. She was actually rather rude, but she finally told me she would review the doctor's notes and then speak to the doctor about changing the code to the one that had been used on our previous visits. I never got another bill after that so I assume they took care of it. You might be able to take care of what you've already been billed in this way, but it may be an ongoing battle that you have to fight every time you visit this doctor, so my recommendation would be to see if you can find another doctor who is NOT located in a hospital. Good luck!

Report this to the hospital licening comission, better business, and check with your insurance to see who you can report this to also send them a copy of the insurances web-sit. See if any of this helps.. Good luck.

Wishing you the best!

I agree with Nancyrae. You definitely need to contact the Agent that sold your or your husband's company the insurance policy. They should be able to help. My husband's Agent is wonderful about answering questions and helping with whatever I need.

The Hospital isn't being right with you though. Also, if you want to help with other people's hospital bills then it should be a choice. It isn't your responsibility to pay for others especially if you can't afford it.

Have you spoke to the agent who handles the insurance you are covering? There is a middle person who should be able to help with this.

The company the insurance is through - yours or hubby's - has an agent that sold the policy to your company. I would try to get in touch with the agent and see what they can do to help.

You were basically screwed all the way around - the dr's office should have told you how it would be billed or how much was / was not accepted. If they billed it under the wrong the code they should go back and make the billing adjustments. If not - tell them you are filing a formal complaint against their office with all involved parties.

If the person who answers the phone with the insurance company refuses to help - tell them you want to speak with a supervisor.

Have your information correct and in front of you - don't take no for an answer - push your way through - what they are telling you is not correct.

I actually work in hospital billing and have been working in healthcare insurance and billing for 15+ years.

When you see a doctor that is a hospital based physician, there are 2 claims that go out. 1 for the individual doctors expenses and 2 for the use of the facility, facility fee or clinic charge. These charges are out patient facility/clinic charges. Depending on what type of visit the facility claim may also include labs, radiology charges, medications, vaccines etc. The payments on these claims do not go towards service for other patients. The facility claim is billing for use of the facility, nursing staff and supplies that are not included in the individual doctors bill.

What you are billed depends on 2 things, 1 what the providers contract is with your insurance and 2 how you insurance benefits process the claim. Most likely this is not a coding issue and has nothing to do with the codes that are submitted to the insurance.

If you call the billing department they should be able to have the codes reviewed for you, but codes can not be changed on the basis of getting a claim paid. The codes submitted have to match what is in your medical records and the services performed.

Insurance companies ALWAYS tell the patient that it's a coding issue, when it seldom is.

What you need to do is get copies of the explanation of benefits from your insurance company for both the physician claim and the facility claim and verify how they processed. Make sure no charges were denied because your provider can only charge you for what shows as patient liability if they are a contracted provider (in network with your insurance.)

After reviewing your EOB if you don't see any problems and they are billing you your patient liability, call the billing office and see if the coding can be reviewed.

The problem is that if they are billing correctly, and you have a patient liability for the services there is nothing you can do except set a payment plan with your doctors billing office.

Feel free to send me a message if you need additional assistance.

One additional things. Regarding your sons therapist, I would suggest to find out why your insurance is not paying. If the therapist is contracted with your insurance they should not be dropping you as a patient, they should be following up with your insurance. You should file a complaint with your insurance and find a different therapist. If you need assistance with those claims let me know. I get insurances to pay claims for a living!

Report the insurer and the Dr and Hospital to the Tx Board of Insurance. Then fight all the charges and refuse to pay the Dr until they accurately file with the insurance.

I have a similar situation and this is how i tackle the problem. Call the doctor office and speak to billing dept (most of the time the billing dept is outsource to another company; make sure you get the person name for future phone call). Explain to them about the "different" code that insurance mention to you. I believe that even though the hospital is in network with your insurance but the specialist is not.Hospital will charge you their facilities but the specialist will charge you their professional fees using out of network rate; make sure you request details billing from both of them and compare them as they sometimes charge you twice & for stuff that you didn't used. Tell the specialist billing rep. that this was not explain to you on the first place and now you are stuck with the balance. So now you are requesting a write off on the balance. Most of the time at this point of time they will agree on you paying 50% of the bills. Make sure you check your insurance if you should only pay 10% deductable and if you do, tell the billing department that you only agree to pay 10% and not more that that. Even if they agree to 10%, do not pay in one lump sum; make an installment payment - they can't charged you interest on medical. I did this on my delivery charges - $20K (paid only +-$1500) and my hubby biopsy - $13K (paid only +-$1000) all in 1 year installment. FYI, not paying medical bill will effect your credit score in a bad way. As for the therapy, the provider should not deny you service because insurance haven't paid them yet & if they anyway, please change provider as they didn't really care about you anyway. Hope this help.

I had a similar problem with Medicare. My doctor ordered a set of tests not covered under a certain diagnostic code. After a year of doing battle with the company billing me I spoke with an agent there who suggested that I go to the doctor's clinic and ask that they switch the diagnostic code so that the procedure would be covered. The jury is still out as to whether or not this will work but at least I will try her suggestion. I am on social security and not prepared to pay for a test I was unaware of, didn't ask for or needed (results were negative.)