Insurance and out-of-network anesthesiologist

[kpgallo]

So here's the basic situation.  I'm self employed and had to really go nuts to get health insurance.  I did find it, which is good.  I'm a pretty healthy 33 y/o (went to the gym at 7am this morning, that sort of thing).  I rarely need to see a doctor.  So, early this year I went to a GI type doctor to get something checked out.  He did the anal scope, the shallower one which I can't recall.  that turned up a couple polyps.  So, we decided to do a colonoscopy.  I got the choice of pills or drink for the evacuation procedure (took the drink.  Here's a tip.  Take the pills), and set a date.

Date of the procedure, his wife is there, who is an anesthesiologist.  We talk for a bit.  I'm pretty nervous, and imagining all sorts of bad news about colon cancer, etc.  A little more talk, then I go under.  Procedure over, I wait a week, polyps are fine.

Then I get the bill for the anesthesiologist.  $1650.  Apparently she's not in-network.  Nobody mentions this.  The past few months have been back and forth with the doctor's billing people and the insurance people, and everybody's response is that this is ultimately my responsibility.  Today I even asked the person at the insurance if it made sense that on the day of the procedure, wearing my robe and everybody on a tight schedule, that I should stop everything and start making calls to them.  She said that that was reasonable.

I talked to the NYS Insurance Department today, and towards the end of the conversation the person said the doctor is required to make sure the anesthesiologist would also be considered in network.  I'd like to get some general opinion as to if that is true.  Any reasonable person, I think, would assume that.

[Amir Mostafaie]

Dear kpgallo,

It is not clear if your carrier is refusing to pay the entire $1650, or they are treating it as out of network & covering it at a lower rate.
Either way you will have to negotiate the charge with the anesthesiologist and you can start by asking your insurance carrier what they deem reasonable & customary. That would be the amount they would have paid if the anesthesiologist was in-network. Once you have that figure, you have to start your negotiation with the anesthesiologist & leverage the fact that she is your doctor’s wife.

It may take several calls & a ton of patience but I know of cases where the provider settled on 40% of the total bill.

Sincerely,

Amir Mostafaie

[HH5]

You're not alone.  This type of thing has been highlighted in recent articles nationwide.  A classic case is a woman goes in to deliver a baby, gets an epidural from a doc who happens to be out of network, and only finds out weeks later when the bill arrives.

If the anesthesiologist is out of network, she is out of network.  To us, that takes the insurance off the hook for this one unless there is something else in their contract.

That leaves the doc.  Was it ethical to pull in his wife who happens to be out-of-network to put you under?  Not really.  I think your case probably lies most squarely with the doctor's office and anesthesiologist.  Our advice would be to offer them $500 as payment in full, and get in writing that it is an agreement.  That way they get paid something, and you don't have to pay $1,650.

But no doubt, this kind of thing shouldn't happen.

http://www.healthharbor.com

[kpgallo]

I'm not sure if this is going to post back to the forum page.  Anyway, assuming it does...

My out of network deductible is over $1650 anyway, so they would pay nothing.

What exactly should somebody do when they go to the doctor?  Forget ethical.  I think this is criminal, if I go to an in-network doctor, and they know that's *why* I go to them, to then do things that will fall out of network.  It benefits both the insurance company and the doctor to have this relationship, where I can't find out what my services will cost until they are already completed, and I'm on the hook.

What if his wife decided she is the best in her field and sent me a bill for $10,000?  I would assume she would have every right to do that.

To answer the settlement question, I was offered $500 to settle by the doctor's billing people.  That offer came in a couple days ago, by the way.  They were sticking with $1650 for quite a while.  Months, in fact.  I do understand that this will put the issue to rest, but I just can't stomach that.  There's something plain wrong with this situation.  If this happened at the bank or car dealership, somebody would be going to jail.

As a doctor, I can understand felling like the insurance companies give you a rough deal, and your patients are often difficult, but what the hell?  There aren't many other fields that give you a bill after the fact.  Right?  I could understand an emergency situation, but this was not that.  There were no surprises.  I was even on time for the appointment, and they were on time with the procedure.

[kpgallo]

Oh, so I forgot to say what I think I'm going to do.  I'm going to call the billing people, say I'm considering the settlement, but I need it in writing, specifically that this covers the bill and that will be the end of it.  Once I get that I'll start the dispute process with the NYS insurance board and all that business, and just hold onto the settlement offer.  So, worst case $1650 becomes $500.  See how that goes.

[kpgallo]

Update.  Won't send me the updated bill until I agree to the settlement, but they agree to $500, even if I appeal with insurance first, which I'll probably do just to make life difficult for everybody.

[monica148]

If you are unhappy with the $500 offer, I would go back to the NYC Insurance Department and conduct all of this in writing so you have a paper trail. Did you as the person you spoke with to provide his or her opinion in writing that the physician is required to make sure the anesthesiologist in within network?  If that is true, you should only be required to pay what is stated in your Evidence of Coverage.  If not, I would think the settlement is the best idea.  Just my opinion...I am from a different state, and do not know the laws within NY.