18 answers

Hospital Doctor Doesn't Take Your Insurance Yet Hospital does...Er Visits

Can you let me know if I have any recourse in this situation?

I took my son to the ER for stitches. The hospital charged a facility fee and my insurance, bcbs, paid it. We then got a bill for the doctor charge. He didn't take BCBS, though the facility did, and so they are charging us $200.

Another instance - Husband pulled all the muscles off his clavicle, took him to the ER. Facility charged and our insurance took it and paid it. Doctor took our insurance. The xray tech did not and charged us $500.

These are not our co-pays. These are specific instances where the doctor didn't take our insurance.

The $500 charge we fought with our insurance since it was an ER visit and they denied it twice. We had to settle and pay $250 out of pocket.

So, from now on, am I supposed to go into an ER and ask everyone who touches us if they take our insurance and wait if they do not? It seems ridiculous that the hospital takes our insurance, yet the doctors inside do not. I really am not happy with surprise bills. I have insurance and I'm already paying co-pays and deductibles.

Has anyone else had this happen? Is there anything I can do?

Thank you in advance.

1 mom found this helpful

What can I do next?

Featured Answers

Doctors are NOT employees of a hospital. They have privileges to see patients in the hospital. And being a preferred provider means taking a reduced fee. Sometimes the reduced fee isn't enough to cover the doctor's expenses. They have to take this into consideration when becoming a preferred provider and that is why not all doctors take all plans. I really am shocked to see so many of you saying they refused to pay or will only pay a certain amount no matter what. How would you feel if you were working for someone who told you that?

More Answers

This is pretty common. I do the insurance billing in a doctor's office. We don't accept many insurance plans, but the doctor takes call at the hospital, which accepts many more insurance plans than we do. In the case you are describing, you need to submit the bill(s) from any provider who doesn't accept BCBS to them yourself and yes, you are going to be liable for anything over what BCBS deems "reasonable and customary", which is all they will pay. You will likely have to pay the bill out of pocket, BCBS will reimburse you directly.

3 moms found this helpful

This is very common. You have to demand in advance that the attending physician/tech/anesthesiologist takes your insurance.

For example, I am pregnant and my Dr. and hospital take my insurance. My insurance just changed and now the the lab they use is out of my network. So I have to remind them every time I go in to send my lab work to a different lab, and sometimes I have to do it myself.

In cases of emergency where you can't control who is attending, I have no clue how to set it up, but you have lots of graet advice on the BCBS.

2 moms found this helpful

I've seen this happen in California as an insurance agent. For instance, one of our clients had to have emergency surgery and went to a contracted hospital. She could have fainted when she got the bill from the anesthesiologist that was on call that night whose office said they would not accept her insurance. She had no control over which anesthesiologist she got. I got it billed as an out of network referral and the insurance paid the contracted rate for what were considered usual, customary, and reasonable charges. The anesthesiologist accepted it as payment in full.

I think the trick is to have a good broker to deal with the insurance carrier or get someone good in claims to assist you with these things. Sometimes you just have to know what to say.
In the case of an ER visit, you have no choice of who is on duty. Ask that it be billed as an out of network referral and usually the provider will accept the payment from your insurance.
I was successful doing this many times with Blue Cross/Blue Shield.

Document every conversation and correspondence including the date, time and person you talked to. Get their extension. If you can't get anywhere with that person, talk to someone else.
Like I said, if you have an insurance broker or agent who can do this on your behalf, that's all the better.

Best wishes.

2 moms found this helpful

I had a situation where I had a planned surgery. My doctor and the hospital were both on BCBS. When the bill came from the anesthesiologist, he did not accept BCBS. He was was with a group of anesthesiologist in the area that I have had before (Pinacle Anesthesia), but they do not all take the same insurance. I fought the payment directly with the doctor. I found out what BCBS would have paid if he had been in Network. I then told the doctor that I would pay him that amount in cash today or I would pay him $5.00USD a month until the bill was paid off. This was not an emergency and they new far ahead of time what insurance I was on and what he would take. They accepted the smaller amount.
I know my situation is a little different, but I am sure they will work with you. Sometimes you just have to get a little mean/firm.

1 mom found this helpful

Happens all the time. I worked at a hospital and one of my employees went in to our own ER and the doctors were not in-network.
The best thing to do is to do upfront research on who is providing care in the ER that you most likely would need to use in an emergency (there is typically one, maybe two "groups" and ask if any additional surgical groups, etc) and find out if and who is in-network. There may be no one. . .
As you pointed out - it was for emergencies so you shouldn't have to use this as a PCP, etc. and consider it a one-time incident.
thank your stars it wasn't more. Additionally, I'd work directly with the physician group's billing office, not your insurance, to see if they could work anything out with the payment structure, maybe treat you as a private pay and offer some level of discount. . .

I don't live in McKinney, so I am not sure if this available in your area, but both of those things could have been covered by a "doc in the box" clinic type place - not the ER. Here in Tyler, we have clinics that are associated with our hospitals, but the doctors that staff them definitely take BCBS. Maybe the ER is staffed by various doctors and not necessarily associated with/affiliated with the hospital? So...my point is...can you look into clinics for those events?

Good luck,

We took our son to the ER at Presbly/Plano and it was the same way - the ER charges their portion and the doctor bills separately. Our insurance covered both except for co-pays.

I had something similar - call the insurance company again, and explain it to them.

When this happened to me, it was the service that reads test results. The hospital only uses one company, and since I didn't HAVE the option to choose a company that did accept my insurance, but the decision was made for me, I wasn't responsible. If there were doctors at the hospital who were on duty, who would have taken your insurance, that might change things, I don't know. But if none of them do, then you are in the same situation I was.

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