HMO claims my sis owes huge Dr. bill!

My sister has a BC/BS HMO plan thru her employer. She went to a dr. for reconstruction following a masectomy and didn't know he was out of her disctrict. The dr. was referred by the surgeon so she assumed he was in network. The HMO now claims the dr. was out of the district and my sister now owes close to $7K. My sister did not have the prescence of mind to do all the checking at the time since she was so upset thinking about the cancer.

She wrote an appeal letter to the insurance company but was denied. Now she will be undergoing chemo and has to think about owing all that money on top of feeling sick from the chemo!  

What can she do now? Does she have to hire a lawyer and does she stand a chance in winning the case? Should she write another appeal letter? Is there an advocate she can turn to?  She lives in Illinois. Please help! Our family is not rich and we can't help her financially.

[Amir Mostafaie]

Dear heart2heart,

In most cases, the surgeon’s office gets pre-authorization for procedures & during that process if it is determined that the patient’s insurance carrier will not fully or partially cover the procedure, the patient is informed. This way if the patient is unable to afford the cost, they can find an alternative solution.

You need to find out if either your sister’s PCP (primary care physician) office or the surgeon’s office disclosed to your sister that she may be responsible for the cost of the procedure. Please note that this disclosure may have been given to her to read & sign! Often patients sign disclosures without reading the information thoroughly.

Sincerely,

Amir Mostafaie