We have been seeing a pediatrician for a few years and recently she switched practices. We have a newborn and checked she was still listed on the providers of the website. We also checked and the other doctors of the new practice are also in-network.
All of our visits were labeled as out-of-network. They said the dr. had submitted a form to get re-added to the network but all visits occurring before she was readmitted would be treated as out of network they would not pay them retroactive when she was admitted back into the network.
Does this sound right. Sounds like they are using a loophole to deny service. They also said it could take 4-6 months to accept the dr as in-network. This sounds completely crazy to me.
When we go the first notice it was being applied out of network I called and the cs person told me over the phone Yes you dr is covered this was a mistake.
If your Pediatrician is willing to accept negotiated rates for all visits from this Carrier, you may be able to work through this conflict.
Your Carrier may be able to consider your first visit out-of-network, but you can argue that the following visits were made based on their customer service agent's advice that this provider was an in-network provider. You need to call the CS again and ask to speak with a supervisor & make sure your call was documented. Most companies either record calls or make a written note in your account, documenting the interaction. Once it is established that their representative has advised you incorrectly, they will be more willing to settle.
This happened to me several years ago. I called a provider and asked if they were members of "X' insurance network. They said yes. I did not call my insurance company, figuring that certainly the doctors office would know if they were members or not.
To my surprise, the insurance company rejected the claim, plus the claims of everyone that doctor referred me to for testing (even though those were ALL in network). They said the provider had merely APPLIED to be a member of "X" insurance network, and had not been approved yet. Thus that doctor, and every one he referred me to for furthur testing was denied based on the fact that he was not in network and I shouldn't have seen him in the first place.
When I called the doctors office, they admitted he was "pending approval" but stated that they assumed they could treat members of "X" insurance company anyway, and that "when he got approved" the insurance company would retro the claims and pay. This was absolutely NOT true, according to the insurance company.
I had to go through 2 levels of appeals, stating that the doctor gave me the same care, testing, and referrals that an in network doctor would have, and that all the referrals were done in network, just as if an in network doctor would have ordered. The doctors office, not surprisingly refused to give me a statement acknowledging that they incorrectly informed me in the first place. I just gave my statement of what I had been told.
On the second level of appeal, the insurance company went ahead and approved it, being sure I understood that no furthur visits to that doctor would be covered until he was in network officially.
Appeal, appeal, appeal. They hope you'll cave in at first. Stick to your guns and keep going.
Copyright 1994-2017MedHelp International.All rights reserved. MedHelp is a division of Aptus Health.
The Content on this Site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. Med Help International, Inc. is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. We offer this Site AS IS and without any warranties. By using this Site you agree to the following Terms and Conditions. If you think you may have a medical emergency, call your physician or 911 immediately.