August 17, 2011,
S.B. asks from Melissa, TX on February 17, 2009
Out of Network Anesthesiologist Bill
I had my baby 20 months ago. The anesthesiologist charged $3300 for the epidural and $200 to change the bag (or whatever) when I ran out. I played the game with my insurance to get them to pay in-network (they consider $1100 reasonable and paid $860, so my part would be $240) leaving a balance of $2640. I had to send the dr a letter asking him to reduce the bill and he cut if by half leaving $1320. I sent another letter asking him to reduce it further to the $240 that BCBS considers reasonable and all I got back was another statement with the $1320 balance. Any suggestions as of what to do? If he goes no further, I'll pay it, but he'll get $5 a month for the next 22 years.
1 mom found this helpful
So What Happened?™
I got a letter that I needed to pay or reply by X date and sent a letter that I required a further reduction to a reasonable amount (and told them the amount) or a detailed/itemized billing (not statement). This happened a couple time and the response was another statement. Finally in Aug, I got another statement with an adjustement on it - to ZERO!! I guess it just takes persistance.
S.K. answers from Dallas on February 18, 2009
Have you tried talking to your OB/GYN sometimes they can call the anesthesiologist and talk with them they should not use a out of network provider
M.C. answers from Dallas on February 18, 2009
We encountered a similar issue with BCBS about a year and a half ago. In our case, our DD was in the PICU, began projectile vomiting, and I pulled in a doctor who was passing in the hall to help. Turns out I was SUPPOSED to say, "excuse me, sir, are you in network? no? then could you please find us a doctor who is, while I stand here with my very sick daughter in obvious distress?" Don't get me started on this one!
We did get it resolved, after months of fighting. BCBS eventually paid the extra fees. Here's how we did it: follow Cheryl's suggestion and contact your HR rep. BCBS doesn't care about you as an individual. They DO care about keeping your employer as a client. So make your employer go to bat for you. The key to getting BCBS to pay the full claim is to establish that you had no reasonable choice in which doctor treated you--this is true in emergencies, and in cases where you are not given a choice of doctors. If they just pulled in an anesthesiologist who you've never seen before while you're in labor, you can make the argument that you were in no condition to choose or protest. That's the argument you need to make. If you were in a car wreck, and unconscious, and the ambulance just brought you to the nearest hospital to save your life, BCBS would pay for it even it they were out-of-network. Read your terms of coverage carefully (I know it's huge and a pain the patootie). You want to be able to cite the page where it says you can use out-of-network if there are no other available options. We had to lodge two separate written appeals, but it eventually got sorted, and we didn't have to pay. I know this is a terrible, stressful thing to go through. GL!
A.G. answers from Dallas on February 18, 2009
I work for a hospital and have helped people in this very situation. Call the hospital and tell them you are upset (be nice) and that you came to that hospital because that is where your doctor delivers and you had no choice in the matter - they can usually work with the group. THEY have the contract that keeps those Anesthesiologist working in that hospital. I hope that helps! Good-luck!
C.S. answers from Dallas on February 18, 2009
Coverage is determined by the employer NOT the insurance company. It's your company (or your spouse's) that you need to talk with as far as what is and what isn't covered. Contact the HR department. They're the people who can help in negotiating payment by the insurance company.
If you were in-network for everything except the anesthesiologist, then you have a case about not paying. Otherwise, if you are responsible, talk with the hospital as well as the doctor's office about a payment plan. They will work with you, especially if you are willing to pay. Some payment is better than no payment -- even for doctors. They have bills too.
V.T. answers from Washington DC on February 17, 2009
I remember my sister had the same problem with her son's surgery. It turned out in her case that because a in-network doctor was not available, her insurance company paid the out-of-network bill. It took her months of fighting with the insurance company, and it maybe just her insurance company that would do it, but it is worth a try. She argued that she would of used in-network had one been available, but at the hospital, which was in-network, they only had an anesthesiologist that was out of network and she shouldn't be responsible for something she couldn't control. I don't know which insurance company she had and this was in Maryland, but it maybe worth a shot if this was your circumstance.
H.M. answers from Dallas on February 17, 2009
Is this doctor out of network or in network? If he is out of network then he does not have to abide by any rate your insurance sets. If he is in network, then he is obligated to honor the contract rate with your insurance. If in network, simply send him a copy of your EOB (explanation of benefits) and the amount your insurance says you are responsible for. If out of network, then you really do not have much recourse, legally. You could try calling your OB/GYN or the hospital you delivered at. I'm assuming you did not choose your anesthesiologist (in the future, you do have the right to do so, by the way). So, you could argue that either the hospital or your OB/GYN should have notified you prior to the delivery that the anesthesiologist would be out of network. You could see if they would be willing to advocate your case for you with the anesthesiologist or you could try calling the doctor to see if he will work with you on the final amount. This is really an isurance issue more than an issue with the doctor, but I think you might have more luck with the doctor. However, you could call your insurance company and ask them to send you a copy of your policy outlining in detail your benefits. You might find that they did not honor your policy. In which case you could fight them. You are an on-going customer of BCBS and might have more clout with them b/c they don't want you to drop your policy. I said you might have more luck with talking to the doctor because doctors are generally more reasonable than insurance companies and he may be more willing to budge because he wants to get paid. Insurance companies very arbitrarily set low rates of what they are willing to pay. I know it sounds like an outrageous amount, but the doctor actually takes very little of that home. I think it's ludicrous that insurance companies have the power to determine what is "reasonable" to pay doctors for their services, but I won't get off on that tangent. I hope this is helpful and not just a bunch of rambling. You can send me a message if you need any more details on how to proceed, and I'll give you any information I have~ which isn't a whole lot.
F.P. answers from Dallas on August 17, 2011
MOST anesthesiologists are out of network, in my understanding. I had BCBS of Texas and went to deliver my baby. I had an out of network anesthesiologist (the nicest guy I have ever met, BTW) and discovered so when I received my bill. The bill was for $3800 (I got an epidural and was in labor for over 13 hours!); however, BCBS only paid 70% of "the usual and customary rate" of $800! They paid $560 and I was responsible for the balance! I called BCBS and was told that was all they would pay. I called the anesthesiologists office and he graciously gave me a 25% discount on the balance and I took it immediately. In speaking to several physicians since then, I have discovered that BCBS is the WORST insurance company in terms of paying doctors. I did not meet a single doctor with a positive opinion of BCBS. All agreed the United Healthcare, Cigna, and to a much lesser extent, Aetna, were superior to BCBS. So, when it came for annual enrollment, I changed to United Healthcare. Then I became pregnant with my second child and also had an epidural placed by an out of network anesthesiologist. However, this time, I was only in labor for 8 hours, the bill was $2800, and United paid 90% of it (even though it was out of network!) and left me a bill of 280! I paid it promptly and became a life lover of United Healthcare. I will NEVER enroll in BCBS again. In speaking with doctors, most are forced to take BCBS because they are the largest health insurer in the country, and without accepting BCBS patients, they would not have enough volume for their practices. I have been seeing with increasing frequency, however, some doctors refusing to accept BCBS.
K.K. answers from Dallas on February 17, 2009
I had something similar happen for a colonoscopy and basically if you are in an in-network hospital, with an in-network doctor, then there must not have been an in-network anesthesiologist and the insurance should cover it. I am not an insurance expert but that is how it was explained to me. If there was an in-network anesthesiologist available, that may change the situation, but doesn't make sense that the hospital would have done that to you.
T.T. answers from Dallas on February 18, 2009
Call your insurance company and ask for and advocate. They have to supply a person to help you through all the red tape of handling your insurance claims. This is a little known service, and I've never had to use one myself, but I've read about it.
Also, what anesthesiologist group is it? I know the one in Plano reduces the fee when you are out of network.
I know it's very frustrating!! Good luck!!
C.L. answers from Dallas on February 18, 2009
I can definitely relate to this problem. I delivered both of my babies at Allen Presby and my insurance was with Unicare. My anesthesiologist both times was Allen Anesthesia Associates. The anesthesia bill was astronomical in both cases as it was out-of-network. Apparently anesthesiologists don't typically contract with insurance carriers so you almost always will get hit with the out-of-network claim. Of course the first step is to work with your insurance provider to get the claim processed as in-network since you didn't have a choice in the matter. This is the easy part as this is fairly common and the insurance provider will usually make an additional payment to the anesthesiologist at the in-net work rate. However, the kicker is what the insurance company considers to be "reasonable and customary". In my case (and yours it seems) this was significantly less than what the anesthesiologist charged. So you can fight with your insurance provider all you want but they will not budge because in every plan they include a clause for only paying what is reasonable and customary. They will say your only recourse is to go back to the doctor to get the payment reduced. Then the doctor will tell you to go back to the insurance company and it becomes a never ending cycle. What worked for me with my first pregnancy was to go to my HR rep and have her plea on my behalf directly with her contacts at Unicare. She was able to get my balance paid by Unicare. I think the HR department has a lot more clout than we do when negotiating with the insurance company. The second time I was not able to get support from the HR department so I let the bill go for almost a year. I was getting monthly invoices stating that the balance was about to be turned over to collections. And then suddenly one month I got an invoice where almost all but about $200 had been "written off" so I promptly paid the balance and never heard from them again. It sounds like you have gotten as far as you can go with both your insurance and the doctor. I would suggest next going to your HR rep and explaining how upset you are and seeing if there is anything they can do on your behalf to have the insurance company pay more. If that fails then honestly I would ignore the bill. If they do eventually send it to collections then you can work out a payment plan at that time. It took me over a year to get it all resolved with both pregnancies and definitely put a damper on being a new mom. I know how stressful and frustrating it is. Good luck and don't give up yet! Sorry this is so long but it is a pet peeve of mine! :)
K.G. answers from Dallas on February 17, 2009
yes-- to keep it from collections pay 5-10$ per month-- if it goes to collections they are a little rougher on you to get THERE $ keep calling the doctor's business office and see if it can be lowered any more since the dr. was out-of network and the hospital was in-network also see if the insurance co. can pay any more too...
S.D. answers from Dallas on February 18, 2009
I had that EXACT same issue when I had my son. The anesthesiologist that was on-call at the hospital I was delivering at, for some reason, wasn't contracted with my insurance so the bill that I received from him was astronomical. Like you, I had to send him a letter asking to reduce the bill, but my argument was that I was not given informed choice. Had I known that the possibility was there that the doc that the hospital had on-call was no contracted with my insurance, I may have been able to choose a different route or ensure that a doctor that WAS contracted be used. However, at the time of labor is NOT the time that I should be confronted with that choice as I'm in a great amount of pain and it would have caused me great distress to learn this. All of this was out of my hands. I asked that I be allowed to pay the cost of what it would have equalled to had he been contracted with my insurance. At this point, it's been a year and a half since that letter was sent and the last time I spoke with the doc's office, it was still being considered. So either it was forgiven in total or it is STILL being reviewed. I don't know if you delivered in a hospital and he was the on-call doc so you didn't really have a choice, but - at the very least - the hospital can assume some responsibility for using a doctor that isn't contracted with the same insurances that they are. That has to come up on a regular basis, I would think...
Hope this helps!