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

Updated on January 04, 2012
B.D. asks from McKinney, TX
18 answers

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.

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answers from Dallas on

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?

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answers from Missoula on

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.

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answers from Houston on

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.

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answers from Redding on

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.

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answers from Dallas on

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.

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answers from Dallas on

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. . .



answers from Dayton on

Had this exact thing happen. The only way I could get it resolved was to get the hospital to accept from me, the amount they would have received from the insurance company. Go back and check to see what the "usual & customary" amount is since they paid it before. Or, you can dig in your heels and get the insurance company to tell you what that amount is. This will be a giant pain, but you should come out way better if you do this.



answers from Dallas on

yes, you DO have recourse, i live in denton and have dealt with this exact issue more than once. contact the ER physician group AND your insurance company, i've always been able to work it out pretty easily once i've explained the situation. good luck!



answers from Houston on

Very very common. Unless it is considered an emergency by legal standards, insurance does not have to pay the ER doc at in-network rates.

I had this same thing happen. Many, many times ER docs are not a part of ANY insurance network.


answers from Providence on

Next time, hopefully not an ER or emergency type of thing..I would ask them if the doctor is a participating provider. Find one that is in the network. If you can't ,contact your BCBS and let them know about your situation. Sometimes they will approve certain situations if you give them prior knowledge. Especially with surgeries.



answers from Austin on

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.



answers from Dallas on

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.



answers from Tyler on

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? point is...can you look into clinics for those events?

Good luck,



answers from New York on

I have had this happen and what happens in the case of emergency visits (and also anesthesiologists) is that BCBS will pay you and you pay them. I am not sure of your insurance but I have BCBS and they have sent me checks several times, including ER visits.



answers from St. Louis on

I have had this happen for anethiesology and lab tests (i.e. xrays, blood draws, etc) so that one is not too shocking. However, the doctor thing is a new one for me. You would think that the doctor rotating through would be getting paid through the hospital physician billing office based on the note he charts in the hospital records. Usually if they are affiliated with the hospital, then they also accept the same insurances the hospital does. It wouldn't shock me though.



answers from Chicago on

This happened to me several times, but not with BCBS. Who doesn't take BCBS???

Anyway, I think most hospitals have a social worker or patient advocate. If you call them up and explain the situation, they will most likely work with you. In my case, any time I got a bill that my insurance considered out-of-network, I called the hospital, and they wiped out my entire co-pay. I was stunned at how easy it was. This saved me more than $1000 dollars. I guess my hospital realized that I can choose any other hospital, and they shouldn't hassle people who have good insurance. Good luck to you!



answers from Madison on

First, call your insurance company and see what you can work out with them.

Second, I didn't realize until just recently that the hospital (or the clinic) and the doctor charges are TWO SEPARATE charges. Why? Because the doctor is considered a consultant and therefore their bills are separate from the hospital/clinic. Wierd, I thought. But apparently that's how they bill things these days.

And I think it's pretty snarky of the hospital/clinic to know what your insurance is and then allow other doctors/technicians to work on you who aren't on your insurance plan. They should either make absolute sure that the only people who touch you also take your insurance--or your insurance company should work with the hospital/clinic to get it resolved. That's just a cheesy way for them to sock it to you when you're hurt or uncomfortable or not with it to ask every single person who comes into your room whether or not they're on your insurance program. I mean, you're stressed out enough the way it is. You shouldn't have to micromanage your own account when you're in the hospital/clinic.



answers from Dallas on

I've had this happen numerous times usually with labs, radiologists, etc.-the doctors you don't have direct contact with. In fact, I just received a lab bill for over $500 because the doctor who worked in the lab was out-of-network. I called my insurance company, Cigna, and they agreed to refile the claim under the doctor who ordered the labs because he is in-network and I had no choice what lab was used. I've had this happen at least once a year with a couple of different insurance companies and they always agree to pay for it as if it were in-network. However, the insurance company will only pay what they deem acceptable for the services provided whether the doctor charges more or not. I would ask for in-network doctors from now on, if possible.

Next question: Question About Out-of-Network Insurance Claims