Insurance Issue - Long - Update

I can't believe this is what I am dealing with. I am so mad, frustrated, and disappointed, I really don't even know what to do.

So as some of you may recall back in January the perinatologist I was currently seeing felt he saw a whole in each of the twins hearts after 2 fetal echos. So he sent me over to Schneider's for a 3rd fetal echo and consultation with a pediatric cardiologist.

Well, the girls at the peri made the appointment for me, and when I confirmed the appointment at Schneider's they asked me what insurance I had. I replied "United Healthcare" they said "no problem".

DH and I go to the appointment. Fill out all the paperwork and at the bottom was some sort of clause that basically said the patient would be responsible for balances not covered by insurance. Before signing it, DH and I both went up to the receptionist and had a brief conversation basically confirming they accepted our insurance (United Healthcare) and that we would not be responsible for any other charges aside from the $35 copay we had just paid. She confirmed. I signed the paper.

Well, yesterday, I get a bill in the mail from LIJ saying I owe $783. My EOB (explanation of benefits) came from United Healthcare as well so I look at it and they are claiming the Doctor is out of network, and I have to meet my $500 deductible before they start kicking in their 80%.

And to add insult to injury for reasons I cannot figure out LIJ is has submitted 2 claims (2 invoices/bills) for the same exact amount so United Healthcare denied the second claim....which LIJ hasn't billed me for yet.

I plan on calling LIJ today....but do I even have a leg to stand on!? While I know some will say I should have called United Healthcare to confirm the doctor would be in network, this has never happened to me before, hindsight is 20/20. No excuse, but in the heat of it all I was devastated my children may be born with wholes in their hearts, and clearly I wasn't thinking straight, but I truly felt DH and I covered my bases when speaking with the receptionist at the office.

And of course, after all of this, the original perinatologist is on crack and there is nothing wrong with either baby.

What the heck do I do!?

****UPDATE*** Called UHC first and explained I don't understand why they are classifying it as out of network when it is an in network facility that I was in. They said the bill was submitted as an office visit not a hospital visit. In order for them to reconsider whether or not to waive the doctor being out of network.

Called LIJ (billing department). She says she doesn't know why the bill was written and submitted twice. And she sees we paid a copay of $35 which would imply the office was in network, out of network patients do not pay copay, just the bill. However, an investigation needs to be opened and she will be in contact with us in 1-2 weeks.

So, hopefully someone somewhere gets their act together and straightens this out. This is really the last thing I need to be dealing with right now.

Thanks for all of your input, girls! You're the best!!

Message edited 3/1/2011 2:08:55 PM.

Re: Insurance Issue - Long

I am so so sorry you are dealing with this. First of all, DO NOT beat yourself up. I never would have checked to make sure the doctor was in network if both the peri's office and the cardiologists office both told you they accepted UHC. I'd call UHC and follow-up with them, explain the story, it's possible that they made a mistake. I'd also call the peri's office again and ask them and see what they can do. Maybe their billing person submitted the claim wrong? You do totally have a leg to stand on. You asked! Hope it all works out!

Re: Insurance Issue - Long

I had an issue once with insurance where my doctor sent bloodwork or something to an in-network lab, but the person who ran the test was out of network.

I called my insurance and they put it through as a 'courtesy'.

I would start with the doctor/LIJ. Explain that you were told they accepted your Health Insurance, now your EOB says they did not, and take it from there.

Remain calm (easier said than done!) and document EVERYTHING - times you call, who you speak with, exactly what they say.

Re: Insurance Issue - Long

That is such a bummer! You are totally not at fault, it really seems like they should have caught that and of course you were all wrapped up in making sure your LOs were okay.

I would def follow up on it but like the PP said, just stay calm and be reasonable but assertive. They should do something for you!

Re: Insurance Issue - Long

Sorry! I had this issue a few yrs ago when
I had to go to the emergency room. My EOB advised the ER I went to was not 'in network' (umm... who the helll is thinking about a hospital being in network when you are having a severe allergic reaction).

They told me another hospital (further away) was the in-network hospital and I should have went there instead for it to be fully covered. Long story short, I had to write a grievance letter, and then they said a 'board would review it'. I think they wound up paying most of it, but I still had to pay a portion more than I normally would have.

Re: Insurance Issue - Long

I had the same issue when I went to Genetic Counseling when they thought DS might have Trisomy 18, and this after my issues with 1st DS . So I did the same as you and signed it.

It was the insurance's issue. My HR person helped get in touch with the insurance company to clear it up, but it did take a while.

It so happened that in our policy it stated that the doctor was supposed to make sure that they were covered under our plan beforehand for pre-authorization. It was not my responsibility. So the insurance company had to deal with the doctor, because it was the doctor's responsibility, not mine. This was told to Stonybrook, and they had to deal with the charges and the insurance.

I hope that made sense.

Re: Insurance Issue - Long

Posted by sunflowerjesss

Well, yesterday, I get a bill in the mail from LIJ saying I owe $783. My EOB (explanation of benefits) came from United Healthcare as well so I look at it and they are claiming the Doctor is out of network, and I have to meet my $500 deductible before they start kicking in their 80%.

Re: Insurance Issue - Long

so I really think the doctor should have told you they were not in network. that happened to me once with physical therapy, I wanted to go to a place right by my office and they called and told me they were out of network and it would cost me xx amount more. I don't think it's fair or up to you to have to confirm that on the spot, especially since you were referred there. I would definitely call both the office that billed you AND your insurance company and explain the circumstance. maybe the second peri can also send a letter saying there was no issue and you shouldn't have to come out of pocket for a false diagnosis?? it just seems WAY unfair.

Good luck either way.

Re: Insurance Issue - Long

Posted by summerbaby11

so I really think the doctor should have told you they were not in network. that happened to me once with physical therapy, I wanted to go to a place right by my office and they called and told me they were out of network and it would cost me xx amount more. I don't think it's fair or up to you to have to confirm that on the spot, especially since you were referred there. I would definitely call both the office that billed you AND your insurance company and explain the circumstance. maybe the second peri can also send a letter saying there was no issue and you shouldn't have to come out of pocket for a false diagnosis?? it just seems WAY unfair.

Good luck either way.

Message edited 3/1/2011 10:34:32 AM.

Re: Insurance Issue - Long

do they bill twice for 2 babies?

Re: Insurance Issue - Long

Does th e second bill have a diff dr's name on it?? It's possible they billed incorrectly the first time

Re: Insurance Issue - Long