Can They Do This??!

[MsDownToMe 2]

Okay- I have BCBS PPO (Network Blue) here in Florida. I had my surgery on 7/5/11. Prior to surgery I called and checked my benefits and was told that VSG is covered with a 10% copay since I had already met my deductible. The surgeon's office made a copy of my insurance card and verified my benefits, and informed me that my co-pay would be $150, which had to be paid up front.....

Well, out of the blue I get a call from my surgeon's office today saying they got notice from my insurance that I am responsible for $1340-WHAT?! So, I contacted insurance and they are blaming the surgeon's office saying that whoever verified the insurance made a mistake and that my surgeon is out of network. The surgeon's office is blaming BCBS saying that they were told my copay was only going to be 10%( which was the $150 I already paid)....either way, it looks like I am going to be left with a bill that is TEN TIMES the amount I was quoted

What do you guys think? How can this be right?! It's like going to a restaurant and getting the menu that quotes your meal as $10, then after you have eaten it, they say "Oops, it really costs $100" Unbelievable!!!!

What would you do???????????

[Adri 40]

It sounds like the doctor's office is at fault. If the doctor is in-network he/she should have a contract or some other documentation to prove this. It doesn't take a phone call to find that out. Regardless of what they were told your co-pay would be, can they prove to you that they are in-network? Something smells fishy there!

[RSREED53 4]

Report this matter to your State Insurance Commissioner--They will get to the bottom of this matter!

[Stacy160 201]

Well, at 10%, that $150 would make the cost of surgery only $1500... sounds like the Dr.s office told you the WAY wrong amount and whoever came up with that amount must have huge problems with basic math. Still though, they verify benefits as a courtesy to you, they don't have to do it, and ultimately, legally, it's your responsibility. Good news is, even if you have to pay the $1340 (meaning that the amount the insurance OK'd would have been $13,400), that's still a heck of a lot less than any of us self-payors dished out!

[MsDownToMe 2]

It seems fishy to me too!! When I contacted BCBS they said it is different in Florida-that the doctor has to be a member of BCBS as well as Network Blue in order to be considered "In Network". What I don't understand is whythis wasn't explained to me when I called to verify coverage and find out what my out of pocket expense should be. The surgeon's office said that every time they contact the insurance company they have to give thier tax id number so benefits and out of pocket expenses can be verified for that specific provider. I can't figure out who is at fault......what a mess.....

It sounds like the doctor's office is at fault. If the doctor is in-network he/she should have a contract or some other documentation to prove this. It doesn't take a phone call to find that out. Regardless of what they were told your co-pay would be, can they prove to you that they are in-network? Something smells fishy there!

[MsDownToMe 2]

I will look into this....I am just flabbergasted that this is happening.

Report this matter to your State Insurance Commissioner--They will get to the bottom of this matter!

[Tiffykins 673]

It sounds like an error by surgeon's insurance coordinator. They might have been an in-network provider, and then it changed. However, I'm with Stacy on this one. Unfortunately, it seems that it's not your insurance carrier's discrepancy, but will fall back on your surgeon's office. I would check and see if the insurance coordinator/verifier has a hard copy of authorization with documentation of your out-of-pocket cost. That will more than likely be your only saving grace. Your surgeon's office should have it documented with who they spoke with at your insurance company, and they should have verified their in or out of network status. Honestly, it doesn't sound like a downfall of your actual insurance company, and you might not have any recourse unless they provided a written statement/explanation of benefit to your surgeon's office.

[MsDownToMe 2]

It still sucks to have to pay ten times the amount you were told by both insurance and the surgeon prior to the operation-that's what irks me! I just keep going over in my mind whether I could have done something different to avoid this situation, but honestly I can't think of anything.....

Well, at 10%, that $150 would make the cost of surgery only $1500... sounds like the Dr.s office told you the WAY wrong amount and whoever came up with that amount must have huge problems with basic math. Still though, they verify benefits as a courtesy to you, they don't have to do it, and ultimately, legally, it's your responsibility. Good news is, even if you have to pay the $1340 (meaning that the amount the insurance OK'd would have been $13,400), that's still a heck of a lot less than any of us self-payors dished out!

[MsDownToMe 2]

This all just caught me off guard. The surgeon himself is pissed and called me directly to ask me "What we're going to do about this...." I didn't know what to say.

It sounds like an error by surgeon's insurance coordinator. They might have been an in-network provider, and then it changed. However, I'm with Stacy on this one. Unfortunately, it seems that it's not your insurance carrier's discrepancy, but will fall back on your surgeon's office. I would check and see if the insurance coordinator/verifier has a hard copy of authorization with documentation of your out-of-pocket cost. That will more than likely be your only saving grace. Your surgeon's office should have it documented with who they spoke with at your insurance company, and they should have verified their in or out of network status. Honestly, it doesn't sound like a downfall of your actual insurance company, and you might not have any recourse unless they provided a written statement/explanation of benefit to your surgeon's office.

[Tiffykins 673]

This all just caught me off guard. The surgeon himself is pissed and called me directly to ask me "What we're going to do about this...." I didn't know what to say.

He wants to get paid. I'm an insurance agent, worked with all types of providers from health/life insurance companies, and unfortunately, it honestly sounds like your surgeon's office screw up.

They need to provide written documentation. Also, I wouldn't trust office staff who is going to say anything to save their ass from getting in trouble. Sorry, I know that isn't what you want to hear, but it's the truth. That person is going to say "Well they told me this ___________________!" If they do not have documentation, your insurance company will.

As for what I would do, I would call my insurance company, and request that if their calls are recorded, or transcribed, documented with notes on your file, that you get copies of those conversations, and any documentation they were sent from your surgeon's office and they sent to your surgeon's office from them directly.

Do not allow your surgeon's office to bully you. They will expect you to take some ownership since you didn't verify the in or out of network status, BUT at the same time, that surgeon pays his staff to provide a service to you, and in my opinion, they failed miserably. PPOs are pretty simple to navigate through their policies. Check your policy for in-network, out-network co-pays, and any out of pocket that you might have even though you've met your deductible.

[PdxMan 4,292]

Maybe I'm missing something here, but I want to echo what Stacy160 posted. I recently had a procedure done where I had a $25 copay and had to pay 20% . So, I paid the $25, and I got my bill for the 20% (~$485), so I am assuming my procedure cost about $2,400. Surely you know the cost of the surgery is greater than $1,500. I was self-pay for mine and paid $10,400, and that was on the cheap! So, is it possible you were told it would be 10% PLUS a $150 copay? (Which still is a bargain, even with insurance)

[MsDownToMe 2]

My surgeon's office collects any out of pocket expenses before surgery. After contacting my insurance company and verifying coverage, they gave me a written verification that I would only have to pay a program fee of $500 and a co-pay of $150, all due before surgery. I understand that this is significantly less than self pay patients have to come up with, but that does NOT negate the fact that I was told the $650 would be all I had to pay out of pocket, and now I am faced with an additional $1340 bill that wasn't anticipated.

Maybe I'm missing something here, but I want to echo what Stacy160 posted. I recently had a procedure done where I had a $25 copay and had to pay 20% . So, I paid the $25, and I got my bill for the 20% (~$485), so I am assuming my procedure cost about $2,400. Surely you know the cost of the surgery is greater than $1,500. I was self-pay for mine and paid $10,400, and that was on the cheap! So, is it possible you were told it would be 10% PLUS a $150 copay? (Which still is a bargain, even with insurance)

[slhobbs81 0]

Well, at 10%, that $150 would make the cost of surgery only $1500... sounds like the Dr.s office told you the WAY wrong amount and whoever came up with that amount must have huge problems with basic math. Still though, they verify benefits as a courtesy to you, they don't have to do it, and ultimately, legally, it's your responsibility. Good news is, even if you have to pay the $1340 (meaning that the amount the insurance OK'd would have been $13,400), that's still a heck of a lot less than any of us self-payors dished out!

AMEN!!!

[MINI-Me 196]

My surgeon's office collects any out of pocket expenses before surgery. After contacting my insurance company and verifying coverage, they gave me a written verification that I would only have to pay a program fee of $500 and a co-pay of $150, all due before surgery. I understand that this is significantly less than self pay patients have to come up with, but that does NOT negate the fact that I was told the $650 would be all I had to pay out of pocket, and now I am faced with an additional $1340 bill that wasn't anticipated.

If you have a written receipt from them that you have paid in full, why are you worried? Are they demanding that you pay the difference? If so, I would show them your written receipt and see what they say then.

[Fusilli66 22]

It does sound like a mistake in the doctors office, but that technically you do owe that amount. First thing I would do would be to call the insurance company and find out what the costs were, what they paid, and what the insurance company says that you owe the doctor. If it is indeed $1340 then I would call the doctors office and tell them that this was not explained correctly, you were told you were paid in full and therefore don't feel like you should have to pay for there mistake. Then I would negotiate a settlement with them. If they do accept other insurances in network, then why should you pay out of pocket more than an insurance company would pay them for something else. That has always pissed me off. They will charge $100 for whatever - Joe's insurance pays them $10 and they accept that in network, but you are out of network so you have to pay the full $100 for the same service that Joe got for $10. Threaten to not pay and let it go to a collection company, they will for sure settle with you because if it goes to collection the doctor will have to pay the collection company a portion of whatever they collect.

I recently did that with my original bariatric surgeon. He was out of network, but he does take plenty of other insurance in network. I got a bill for $1400 for 3 visits - 1 consultation with the doctor (all of 15 minutes) and two visits with a Physicians Assistant or Nurse (not sure which) where they weighed me and I left. This was worth $1400???? I ended up negotiating it down to what the insurance company would have paid and the whole thing cost me $260. Try that.