[notquiterite]

Should A physician inform the patient that there health care provider is out of there network before they perform a costly procedure??

[shygrneyzs]

I do not know if that is the physician's responsibility. When I moved here with my youngest son, I was out of my insurance network and did not realize it until after the fact. It was up to me, the clinic and insurance told me, to notify the insurance company and seek out of network permission for my son to be seen by a doctor where we moved to.

[Fr_Chuck]

Most physicians don't have the slighest idea if another physician is in or out of a plan. To be honest many doctors are not always sure what groups they are part of, they have to check with their billing departments.

It is always the patients responsibility to be sure that all of the doctors and or facilities are covered under their own plan.

[LearningAsIGo]

It is the patient's responsibility to check with their insurance company before allowing a procedure if it's a concern to them.

I work for a specialist group practice and we employ someone to verify benefits BEFORE they are allowed to make an appointment with any of our doctors due the extreme expense. If they are not eligible through insurance we counsel them toward more affordable options determined by the individual's coverage.
However, doctors do not have to offer this service and you will find that many do not have a benefits specialist available, but rather outsourced billers or others who are not qualified to determine these things for you. As Chuck said, doctors sometimes don't even know what insurance networks they themselves are a part of. (I know all 7 of the docs I work for don't!)

The best thing to do as a consumer is call the 1-800 # on your insurance card and ask to verify coverage for x-y-z procedure and/or doctor's visit. When you do so they can also inform you of any possible charges (copays) you may have.

[ScottGem]

Well it depends here. Every doctor I go to asks what coverage I have and takes a copy of my insurance card. I would think it would be the responsibility to the physician or his staff to let you know at that point, if the physyican accepts your coverage.

If, however, the physician never asked what coverage you have, then it would have been your responsibility to check whether that accepted it or not.

[notquiterite]

should A physician inform the patient that there health care provider is out of there network before they perform a costly procedure???

I got allot of response from this question. Allot of people say that I should have ask and it was up to me. The funny thing is I did ask before I made my first app. I always do that before I see a new DR. And when I asked they said they took my insurance. They also said they got clearance from my insurance for my first procedure. It was then that they were told that I was out of network. They proceeded to do 2 procedures after this. I also tried to give them a copay every time I left the office. They said a copay was not needed. At this point I was thinking I had really good insurance. Then 1 week before my third and final treatment I get a explanation of benefits from my insurance informing me that I was out of network, and now the Dr. is suing me for 11,000$. Wouldn't you think they would have questioned or set up some kind of a payment plan as to how they were going to get paid before they continued? These procedures were 4,000$ a pop. First they tell me they take my insurance, then every time I try to make some king of a copay they say it's not needed. Then after all is said and done... they tell me I'm out of network and owe them all this money. Now I'm sorry I think that is very very wrong. That's like going to a 5 star hotel them telling you that they except visa, them after your stay when you go and check out they tell you they only except American Express. That's misrepresentation in my book. I could see if I didn't ask. But I did. And not just once. Before my first treatment they said they had to get authorization, which they did and were also told I was out of network.I asked them then, they said everything was fine to continue. Then I asked again every time I tried to give them a copay. Yeah real fine. I'm being sued real fine. That's how fine. All you people out there that have answered this question. Some of you say you work for Dr.'s. Your going to tell me this is ethical?? Come on! You all have got to be kidding me. Please there has got to be someone out there that really knows if this an ethical practice.

[J_9]

In all honesty, your post is a little confusing.

You should know whether your doctor is covered by your insurance and is in your network. You can do this by contacting your insurance company prior to any visits, or look in the manual that was given to you to find out if this particular doctor is covered by your program.

It is YOUR responsibility to know whether this specialist is in your network. The physician himself/herself will not necessarily know this, but his billing office will.

We have to be proactive in our health care, but we also have to be proactive in our health care administration. These are all things that you should research prior to signing any consent for any treatment whatsoever. Never, NEVER, NEVER go into a procedure without knowing what is or is not covered. This is the patient's responsibility as much as it is the provider's.

It seems that you may have an uphill battle here.

[ScottGem]

I'm not so sure its uphill here. You did inform the physician of your coverage. You relied on their office's advice that they were participants and their services would be covered.

If you can prove to a court that they were aware of what insurance you had and that they advised you they participated and the services were covered, I don't think they will win.

While its your responsibility to make sure you are covered, I think that giving them a copy of your insurance coverage and asking them (the office staff, not the doctor) specifically if you were covered satisifies the due diligence requirement.

Of course, in future, you should get precerts from your insurance company directly.

P.S. PMs should only be used for personal correspondence, please don't PM questions or followups.

[LearningAsIGo]

notquiterite-
Since you copy/paste the message above to me in a PM, I'll just respond here as well.

The problem is the term "ethical" that you are using. It has nothing to do with the doctor and his "ethics". This is an issue with your doctor's billing department. He's hired those people to be responsible for these things and it has nothing to do with ethics that must be practiced by a physician. He is not at fault here and in fact may very well loose money due to what happened.

There was a mistake in the communication somewhere down the line. Did your insurance change at any point? WHO did you talk to (get a name of a biller you actually dealt with)? You need to write a letter to the billing department explaining everything you did here... in writing. Ask them to set up a payment plan and work with you to come to an understanding. If you don't feel like this is enough, contact a lawyer.
None of us on this site knows all the details to your case. You had only asked a simple question before, so we answered you the best we could. I had no insurance when I was diagnosed with cancer. My bill was over $11,000 too.. I can sympathize with your problems. However, you must continue to contact the insurance company and doctor's office to get this resolved.

Your consent paperwork may hold the key. If you signed them and they stated you were not covered, you won't win your case. However, if that wasn't mentioned, you could have something to stand on. Basically, you have to have something to PROVE what you were told, not just a "he said she said" scenario.