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Out of Network and In Network
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Out of Network and In Network

I had an upper endo at an outpatient setting owned by the Gastro Dr's group. My primary Dr referred me, I have Health Assurance/HealthAmerica through my employer, it is HMO without the need for referrals. I use the referral as I always had to do it with my other HMO. So I went to the GI Dr because he was deemed in network, along with the endo place, as my primary is the one that wanted the endo preformed to begin with. Anyway, nothing was said about it not being in network, everyone agreed I could have it done. So months later I recevied a EOB in the mail stating the claim was Above the Out of Network Cost, and they only cover 490 of the 1400 claim. Stating I would have to cover the 910 because it was over the out of network cost. I am in the process of sending a letter to insurance company asking about how they processed it, etc. I don't understand I have met my deductible and my out of pocket expenses for in network cost, but have not touch my out of network deductible or out of pocket expenses.  So if they processed it out of network, won't it be added towards my deductible and out of pocket expenses? Also is there some clause that some Dr's or personel are out of you control with whether they are in network or out of network? Do I have any grounds to stand on because I went to an in network Dr and in network surgical place? Any suggestions on what to do if insurance comes back with negative remarks?
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Dear Kryddle,

It sounds like your insurance only considers $490 of the $1400, reasonable & your provider (not being in-network) doesn't agree with your insurance! As a result you have been balance billed the $910 which doesn't go towards any (in or out of network) deductibles!

As for your insurance goes, there isn’t much you can do! In addition to what you have planned to do, you need to leverage your relationship with your doctors (both primary & Gastro) and ask them for help! Explain that you trusted them to get you the care you need in the most efficient way & that includes financially, and in these tough times if there is a way they can help you.

Sincerely,

Amir Mostafaie
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