[citylover]

I had surgery using a provider and provider facility under my plan. The insurance company covered the majority of the cost with only $34 to pay out of pocket.

The problem is the cost of $850 for anesthesiologist and the sedation I had. They first only paid $35 of the bill. I called and then they upped it to just over $480. They are leaving me with over $300 to pay because they said the anesthesiologist was not a provider. Well the facility is under the plan and they use this Sedation service which I had no choice over , so I feel I have grounds to appeal and they should pay.
What do you think?

[Fr_Chuck]

Yes, I feel the same way but guess what, nope, you will find the same with ER doctors, most are not under the insurance plans ( none of them) but many work for ER groups.

So by the insurance policy rules, only those providers with agreements have to accept the plan payments.

So the issue is not what the insurnce paid, but what the anesthesiologist charged, the insurance paid the amount they would have paid a plan anesthesiologist,

So you will not win your appeal, I have been there and tried that.
Your issue was not having an arrangement or payment agreement with the anesthesiologist before surgary and "ASSUMING" just because the hospital was under the plan, the independent doctors in the hospital would have to be.

But what the heck, an appeal is free go for it

[citylover]

Thanks FR_Chuck
I guess I need to just pay the balance then and not waste time.

[jef1056]

Fight it with the hospital. They should require those practicing within their building to accept the same insurance they do.

[LearningAsIGo]

I would bring it up with the hospital billing department. Surgery is a major expense and hospitals should be checking that everyone involved in YOUR surgery is covered by YOUR insurance. (It saves the hospital money- if they operate on someone who is not covered, they run the risk of not getting paid)

Its possible the anesthesiologist that was actually present was not originally part of the scheduled team... maybe he/she had to be brought in to cover? Either way, its not your responsibility in a hospital setting to make sure every employee is covered by your insurance.

It sounds fishy to me and its very possible either the hospital billing staff or insurance company made a mistake. I would appeal if I were you.

[ScottGem]

When you checked into the hospital, you told them what coverage you had. The hospital was responsible for using a service that was covered under your plan. Talk to the hopsital and if they don't take care of it, pay the anesthioligist and sue the hospital for what you had to pay.

[citylover]

The Insurance company has referred me to this section of our benefits booklet:


You have a choice of using Network Providers or Non-Network doctors and other health care providers. The Network Providers, under a contract with PHCS or Blue Cross of California, have agreed to provide their services at a discounted rate. This means that your costs will usually be less if you use Network Providers; your cost will be greater if you use Non-Network Providers. The choice is yours. While you make the choice that is best for you, it is also true that circumstances can dictate the use of a Non-Network Provider. Hospitals, laboratories, physicians and other medical providers agree to join a Preferred Provider Organization (PPO) network individually and independently of each other. Therefore, it is possible to select a Network Hospital but
Be assigned a Non-Network Provider (such as an anesthesiologist) or for a network doctor
To refer your laboratory work to a non-network laboratory.

In general, the use of a Non-Network Provider is more expensive. Unlike a Network Provider, a Non-Network Provider is not under contract to a PPO network and has not agreed to provide services at a discounted rate. Instead, Non-Network Providers are free to charge a typically higher rate for their services. Therefore, in cases where a Non-Network Provider is used, regardless of the circumstances and whether you had foreknowledge or control, the Fund has no choice but to reimburse at the
Non-network rate based on the scheduled allowance. The Fund cannot provide the benefit of a PPO discount unless we receive the discounted rate.

[ScottGem]

That's pretty standard language. But it doesn't answer my question. The hospital knew what coverage you had and they would have known what the anesthesiologist accepted. They should have informed you there were using a non paritcipating physician.