Ny insurance nightmare

[Wheetsin 714]

Should probably put this in the Insurance forum but it's something that apparently can pop up at any time and I want to make sure people are aware of the possibility.

All along I've kind of thought it was too easy, nothing went wrong... well, now it has. :target: Consider this a heads-up and watch out for something similar, because I'm now in telephone hell caught in between my insurance company and my anesthesiologist's billing service.

My insurance company covered LB at 100%, and I used in-network everything. My only responsiblity was copays. Insurance company confirms this.

Yet the other day, more than 10 months after my surgery, I get a bill for $$$ from the anesthesiologist office. So I call insurance company and they say that's crazy, we paid it, by law they're not allowed to bill you for anything, we'll take care of it.

I call anesthesiologist office back (AO for short), they say, "Oh they're so stupid, they don't understand their own policy, we'll take care of it."

This week I get a cc letter from insurance company to AO saying, "We have reviewed the claim and it is denied."

I call AO back. Per their story, my insurance company requires anesthesiology services to be broken in half, with half billed under the anesthesiologist and half billed under the MD. Again, this is insurance company's policy. So AO sent the two half-bills out to the insurance company, but only received payment for one... even though insurance company seems to believe they've paid the full balance.

I call insurance company and they say, "We paid that, here's the amount <they confirm the half amount, and it's half of what was submitted>, and if they keep billing you it's a breech of policy and they could lose their contract with us."

So what it really boils down to is someone (my thought is the insurance company) not understanding their own policy.

So I call insurance company back and say something like -- I think there's a confusion, I'm not getting a balance bill, I'm getting half of the actual bill because your policy requires a bill be split into two, but you only paid one of them. They say, "That's not our policy". Anesthesiologist billing says, "That's their policy." I call insurance company back and tell them I want something done about this, as I'm getting a $$$ bill that by law I'm required to pay, but I'm in contract with them to cover it and their contract with me states they will pay. They say, "You can't be held liable, don't pay it because we will not reimburse you if you pay something that isn't an agreed charge."

*SIGH*

Current state is that the AO called insurance company again, apparently made sure they understood they weren't happy, and demanded a claim be re-filed and escalated. They called me after this, told me about it, and gave me the person's name and a reference #. After this call I called insurance company again and told them that at current I'm the one responsible for the $, but it's in my contract that they pay it, so I need to talk with someone who understands what they're doing. I'm told "nothing can be done until a determination is made on that appeal, but I think it will go through just fine." And it's reitterated to me that if I go ahead and pay this amount, they will not reimburse me for it.

So I talk to someone I know in the insurance field - granted this person is an underwriter and not in claims, but her advice is to call the insurance company back and threaten to make a report to the NAIC. But I hate operating under threats.

Anyone out there familiar with the insurance/medical billing world? Any advice? Have you ever heard of something like this -- where an insurance company supposedly requires a bill be split, but at the same time is unaware of that being their policy? Crimeny!

And for those out there not in the position to advise -- at least get a heads-up from this. I had no reason to believe I would have any problems, and now I'm responsible for $$$ that at the same time I shouldn't have to pay. And insurance company says "don't pay it or your loss" while AO says, "If you don't pay it they'll put it into collections, there is no pending status until this gets resolved".

When you get down to it, if I have to pay the $$$ then whatever, I'll pay, my band is worth much more to me. But I'm not going to pay it when I really shouldn't be paying it, and someone's head being up their @ss is the reason why it's coming to me.

So beware.

[ReneBean 3]

Well - I don't know much about insurance - but from my experiences in trying to get the initial approval from BCBS - it is NO SURPRISE that your run of the mill person answering the phone at the insurance company doesn't know their own policy.

I do know that I knew up front that the Anesthesiologist had to be paid separately and that the insurance wasn't going to cover that part. Since I had THOUGHT I was going to have to pay as much as 20% of the total bill, I didn't really care. Nor did I think to question the Why of it.

Sorry I can't be more help - all I know is that it is more than possible that your insurance people don't know their own policy.

[TracyinKS 7]

I had almost this same problem when I had my son, except that the hospital used an AO that wasn't in network......

For me it was an easy fix, the insurance company demanded a write off, because I didn't have a choice of the AO.

If this continues to be a problem and you keep getting the bills, I would get a hold of your main Benifits person and get them involved (they may have to make a call to a corporate BENEFITS COMMITTEE) basically the head hauncho will call the insurance head hauncho and they will get it fixed....

[Alexandra 55]

Wheetsin, you have two points of argument with your insurance company here. The bottom line is that this bill is NOT your responsibility.

If the anaesthesiologist is in-network, then by definition they must accept the insurance carrier's payment as payment in full. If they didn't get what they think is their entire due, their argument is with the insurance carrier, not you. Your role is nothing more than being a facilitator for getting this bill paid, as a favor to the provider.

Of course, you are being billed by the provider and they're telling you they want you to pay so you feel responsible. But your carrier must make it right; if you find yourself in collections you have grounds for a suit and believe me, they don't want to go there. The billing people at the medical office are just bulls moving forward--all they see is that someone has to pay. Don't let them scare you.

If you don't get satisfaction from the insurance carrier, call your state department of insurance or health or whoever has jurisdiction. You're being billed for a cost that your carrier should pay, and you need help resolving it.

Good luck!!

[piercedqt78 658]

Wheetsin, send a $1 payment to the AO, then they cannot put you in collections as you are attempting to make payments. That will hold them off until the Ins company can get their heads out of their collective asses. ~Mandy

[nataliec 0]

When I've had this trouble with other types of medical bills (contradiction between insurance company and medical office) I have opened a file with the state insurance commisioner's office. That is what they are there for, paid with tax $, to look into situations just like this. I have always gotten quick resolution when I have used this resource.