another health insurance sucks post UPDATE #11

[ktgrok]

Just looked at some recent insurance info on the website, and it shows all sorts of problems with my recent ultrasound. Most importantly, they applied it towards my OUT of network deductible, when the facility is IN network! Also, they are only covering half the charges, saying that they won't pay for both a transabdominal and a transvaginal ultrasound, even though both were performed. I just sent them a message via the website trying to figure out what the heck is going on. I even double checked again, and yes, the facility is IN NETWORK! According to my insurance company's own website! Plus,the facility verified my benefits before I went!

Edited August 10, 2016 by ktgrok

[Alessandra]

There have been a lot of situations in my area with facilities being in network and radiologists being out of network. Could that be it?

 

I agree with you that our system is dysfunctional, to say the least.

 

You have out of network coverage? For individuals in my state, there is no plan with out of network coverage (unless extreme emergency).

Edited August 10, 2016 by Alessandra

[cjzimmer1]

It's possible that the facility that did the ultrasound is in network but it doesn't mean that the technician/doctor who performed/checked the ultrasound is in network.  I once had surgery, where the hospital and doctor were both in network but the anestegiolist (sorry I can never spell that word) was not.  I had to pay out of network benefits for that.  I complained to my insurance because, it's not like I knew who be the anestegiolist to verify in advance nor do you get any say in who is assigned to you but it was a no go.  They refused to cover that person at the in network rate and I had to pay the difference.

 

Hopefully you will be able to get in straightened out but I learned the hard way that just because a facility is in network doesn't mean everyone who works there is as well.

[kewb]

It can also be the standard operating procedure to deny charges in the hopes that you will give up and go away.

[mommyoffive]

ARGH

 

That is so frustrating.

[Alessandra]

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn't ...

NYTimes for iPad – Breaking Lo...

Sep 20, 2014 - Insurance examiners “are not in the room

 

I can't seem to link this, goes right to my NYT app, but it's a disturbing story about billing for drive-by surgery.

[ktgrok]

Yeah, this is crazy. I mean, there is NO WAY to know what radiologist is going to read the ultrasound report, you know? If the facility is covered, but the radiologist isn't, that makes no sense, there is nothing you could have done there that doesn't require the radiologist! And the bill and EOB doesn't list a doctor's name, just the facility name. which is in network!

 

I am tempted to call, but I'm honestly working to try to stay low stress ,and somehow I doubt that conversation will do that. Better to wait and see if they email me back I imagine. 

 

The only thing I can think of, is that the midwife that scripted out the ultrasound is out of network, BUT, when she scripts out labs to an in network lab, they pay at in network rates. And if you use an out of network lab with an in network doctor, they charge out of network. In other words, it has always been that the place doing the service is what counts, not who scripted it out. 

[Josh Blade]

Yeah there's nothing good about health insurance these days... Both our primary care physician and my wife's obgyn are out of network now when they were in network at the beginning of the year. While we're stuck with them until open enrollment, they can apparently change whatever they want whenever they want. 

 

Our daughter was born on 12/31, so we had to pay 2 deductibles (one for 2012 and one for 2013), even though we were assured by our health insurance liason through work that one pregnancy would be one deductible even spanning calendar years. 

 

Our insurance decided to charge separate deductibles for mother/baby for our son, so we also had to pay two deductibles there as well. 

 

We constantly have problems with our insurance not fully covering child wellcare (vaccinations/tests in the first couple of years). 

 

More to your point (instead of me griping), my wife ended up having an emergency hysterectomy with our son and there was apparently an assistant surgeon who was out of network on the surgery. We argued with the insurance company and hospital about it since we had no control over it and never even knew he was there (despite meeting 3 other surgeons / anesthesiologists that worked on her) and we were in an in network facility. They eventually paid it or the hospital/doctor dropped the charges. It's all a major headache (it was months of going back and forth with the insurance company 'reviewing' it each time), but if you stick up for yourself, you can get it straightened out. 

Edited August 10, 2016 by joshblade

[magnificent_baby]

I never get too riled up over initial insurance issues. A lot of times they are coded wrong, or adjust them easily with a phone call in out of network situations. Once I paid the out of network doctor the difference and my insurance reimbursed me. It wasn't a big deal. 

[Janeway]

Just looked at some recent insurance info on the website, and it shows all sorts of problems with my recent ultrasound. Most importantly, they applied it towards my OUT of network deductible, when the facility is IN network! Also, they are only covering half the charges, saying that they won't pay for both a transabdominal and a transvaginal ultrasound, even though both were performed. I just sent them a message via the website trying to figure out what the heck is going on. I even double checked again, and yes, the facility is IN NETWORK! According to my insurance company's own website! Plus,the facility verified my benefits before I went!

I am thinking your doctor should not charge for both. I know that transabdominal is generally always done with transvaginal..but then only the transvaginal should be charged for, not both.

[ktgrok]

I never get too riled up over initial insurance issues. A lot of times they are coded wrong, or adjust them easily with a phone call in out of network situations. Once I paid the out of network doctor the difference and my insurance reimbursed me. It wasn't a big deal. 

 

 

And...this is the winning answer!  I went ahead and called, and it seems they are "having a problem with the claims system" and "this is a known problem" and they will send it to the right department and the issue should be resolved shortly. 

 

So, a mistake. Aetna contracts with another company for our claims processing and they messed up. 

 

Now, to continue waiting to find out if I'm going to get the out of network gap exception for my midwife....but that's a whole other ball of wax. 

[G5052]

It's a constant battle.

 

One family member actually is such a "frequent flier" (i.e. 2-3 specialists a month plus multiple surgeries/procedures a year that defy the protocols), that they assigned a case manager within the insurance company. Now we get it started, and then call her. The specialists know to work with her.

 

We just booked a surgery for later this month, and it took a week to get everything together because it's well outside the norm.

 

I always tell people to thank the Lord for good health. If anything medical gets complicated, you have three battles to fight -- the problem, your insurance, and potentially your doctors. Hopefully you find a good doctor and don't have too many problems with that, but it varies.

Edited August 10, 2016 by G5052