Have you seen the dreaded "Out Of Network Service" stamped on your insurance paperwork?

GregP_WN
GregP_WN Member Posts: 742
edited April 2020 in General Cancer
It gets frustrating dealing with medical bills and the insurance that is supposed to be paying for them. You buy a policy that says it will pay XYZ if you have ABC happen to you. But then when you get your "Explanation of Benefits" from your insurance company you see that a large portion of charges were not covered because they were "out of network".

It gets confusing, our blog post today has some information to try to help you figure it out. Take a look at it here>> https://bit.ly/2Sdmkbl and please share it with others using the share buttons on the post.

Comments

  • CASSIEME1
    CASSIEME1 Member Posts: 30
    edited April 2020
    I have with a lab . fight it call your insurance company get all the information from the doctor office.it took me 2 months to clear it up. I asked my doctor not to order that test because my insurance will not pay for it. I am going to also ask them not to order and send out with out prior authorization and make sure it goes to an approve lab because I can't afford these .
  • BuckeyeShelby
    BuckeyeShelby Member Posts: 196
    edited April 2020
    Cassie, most of the plans with the TPA I work for have what we call an "ology" benefit. It's stuff like if you go to an in network hospital, but your anesthesiologist is out of network, it will still be paid as in network because you have no choice in who that individual is. In an instance like that, always check with you carrier. If the out of net provider's claim get there first, insurance might not know you had gone to an in network facility until that hospital claim comes in. Hope that helps...
  • GregP_WN
    GregP_WN Member Posts: 742
    edited April 2020
    My latest hospital stay is shocking at the amount not covered by my insurance. Also shocking is that a charge for 8,000 is "repriced" to 600 and paid at 80%. How is it that 7400 can just be wiped out? That shows how much everything is overpriced so that the insurance company will pay more than they should for some charges to make up for those that don't get paid enough on, and for those who are uninsured who actually get to be treated. It's a practice called "cost shifting" and has been around for many years.
  • LiveWithCancer
    LiveWithCancer Member Posts: 470
    edited April 2020
    I hate dealing with insurance. HATE it!!!! It is confusing and it seems to me that it always, ALWAYS goes the insurance company's way ... and that way is NEVER clear to me. I feel so fortunate that I rarely have to deal with insurance ... it would be in a stack of "round to-its" that grew larger and larger because I hate dealing with it so much.

  • BuckeyeShelby
    BuckeyeShelby Member Posts: 196
    edited April 2020
    Oh naive Greg... I looked at a claim this morning that was billed at over $25k that the allowable was $1500. And before anyone looks at me like that, I work for a TPA, which means, we just do customer services and pay the claims. The employer also contracts w/a network, like the big guns -- Aetna, UHC, Blue Cross, Cigna, etc. They pay to use that company's contracted doctors, so we are NOT the ones setting the payable amounts. Kinda makes me nauseous sometimes, too. Why can't they bill regular people like they bill the insurance, amount-wise.? I can't answer that one. Well, yeah I can. The almighty dollar.
  • Lynne-I-Am
    Lynne-I-Am Member Posts: 89
    edited April 2020
    Yes. A few years ago ( before Medicare ) we were vacationing hundreds of miles from home. We were enjoying ourselves so much we decided to stay a few days longer. I was due for some medical tests and decided to have them done at the local hospital. We called the hospital and asked if they took our private insurance , they responded they did. My husband did not think to ask about networking and they never volunteered the information. After returning home- SURPRISE! bill for several hundreds of dollars arrived. Nothing like the thousands of dollars others have suffered but a lesson learned.
  • BuckeyeShelby
    BuckeyeShelby Member Posts: 196
    Something else to be mindful of: Never ask if a provider "takes" your insurance. Yeah, they could accept the payment, but that does NOT mean they are in your network... Always ask the provider if they are in network with the specific name of your insurance carrier (Cigna, Blue Cross, Aetna, etc). And sometimes it IS more specific. For example, a lot of our groups use Aetna as a network, but for most it is specifically Aetna Signature Administrators. This info should appear on your insurance card.... Again, hope this helps. And remember, it's not that I am smarter than ANY of y'all. It's that I've done some variety of insurance for over 20 years...
  • Shoeless
    Shoeless Member Posts: 18
    I have been having this problem with Aetna for some time. I call them & they say the provider will have to call them. I call the provider & they tell me Aetna will have to call them. They both refuse to talk to me or call the other party. I keep getting the runaround. The last instance was an urgent care/off hours care visit which I know for a fact was billed as urgent care but Aetna took it upon themselves to change it to ER which has a much higher copay. After several calls to both parties regarding the bill I got, I can't get anyone to fix it. Finally I just sent the provider the amount I owe for an urgent care copay, with a letter saying it isn't my fault that you and Aetna can't play nice with each other and nobody is willing to fix the problem. I am sick and tired of paying more than I'm legally required to pay. If you want the rest of your money, call Aetna.

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