Health Insurance Not Paying Doctor That Helped with My Daughter's Delivery

Updated on March 31, 2009
A.L. asks from Houston, TX
5 answers

Hello moms,
Last August I gave birth to my baby girl. She came a little early than planned, she arrived at 3:30AM. My OBGYN is covered by my insurance and we've had no problems with CIGNA (our insurance) paying her services for that night. However, that night she requested a Surgical Assistant, no problem so far. Now our insurance is telling us they are not paying for his services since he is out of CIGNAS network and they don't see the need of using that kind of professional during the procedure. They say a nurse could have helped during the C-Section.
We are at a loss since with my first child we had another insurance and did not have to deal with this. We used the same Doctor (my OBG that I adore).
Now we are waiting for the Surgical helper to send us the bill for the $2500 he charged for that night.
Anyway has anyone experienced something similar???
It was completely out of our hands when my Doctor chose that particular guy. I was in pain and the last think my mind was , "mm I wonder if this guy is covered by CIGNA network" hahaha
Any help please will be very much appreciated!!

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answers from Houston on


I've got fantastic coverage under CIGNA, but you have to figure our how to work the system.

Do not expect the hospital billing department to continue to submit this billing. They will usually only do it once or twice unless you are able to get an authorization number from CIGNA. Keep in mind that it could be a billing error in the way it is being coded...if it happened at 03:30 in the morning, I assume it wasn't scheduled! That makes it an emergency and then the rules change regarding your coverage. If you were already planning a c-section, it might have been accidentally coded that way. Remember that the billing department just enters what gets sent to them.

Now that I've got that out of my far you get with this may depend on which CIGNA plan you have. HMOs can be really difficult...but with PPO or OAP you probably have out-of-network benefits that will pay at least a portion of the bill (after deductible).

Last...don't be afraid to call back multiple times. You would be amazed at the different results depending on the person you get on the phone.



answers from Odessa on

You may have to get your doc to write a letter of medical necessity and send it in to the insurance company. If they don't pay up after that, file a complaint with the Texas Department of Insurance. You can find out online how to file a complaint. If you have any questions, just send me a message and I'll tell you more.

Good luck!



answers from San Antonio on

If need be, make payment arraingment with the uncovered doctor so he doesn't send you to a collection agency. The collection agencey could report you to a credit agency and then it will be a buggar to get that off your credit.



answers from Corpus Christi on

First I would absolutely fight tooth and nail with the insurance company letting them know that it's not your problem who a doctor chooses to assist them. Do they cover each individual doctor if you have to go to the emergency room for something. I know that if you go to the ER around here the doctors are not affiliated with the hospital, so do you have to check and make sure that the doc is in the network when your arm is hanging off?!?!? Second I would ask the hospitals billing department if there was some other way they could code that cost so that the insurance company saw that it was nessicary. I have tricare for myself and my family and everything is a coding issue. Best of luck to you.



answers from Houston on

I have worked in insurance for many years and currently I am working in Insurance collections for a University Hospital.

Did you receive an EOB from Cigna? ON the EOB it should show you what your responsibility is. Since you had no choice regarding this surgical assistant, you should not be responsible for the charges. If the charges are showing as patient liability I would get a claims customer service supervisor on the phone because hospital in patient services are to be pre certified by the hospital and you have nothing to do with that.

Your physician/surgical assistants office should be fighting with CIGNA about payment on this. They are probably submitting and appeal with your medical records.

Please let me know if you need assistance reading your EOB, they can be confusing. Or if you need any additional help!

Reba :0)

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