What do you do if you didn't know a doctor was out-of-network?

Answer 1

Go to, don't call, go to the hospital administration office and demand to speak to the CEO. Tell the hospital CEO your problem. Tell him/her that the hospital did not tell you that this may happen and that the anesthesiologist is not cooperative and will not give you a discount. The CEO does have some influence, not total control, but some influence with the doctors that practice at their hospital. Most hospitals have a disclaimer that informs you of this possibility at the time services are received. Good luck and be aware next time, this happens a lot more than you know.

There are several options in this situation. Much will depend on the contract of the insurance. No one picks their anesthesiologist these days, so this often happens. Anesthesiologists know this and don't contract with any insurance companies, sometimes.

Many policies have a provision that pays the Anesthesiologist based on a percentage of the surgeon's fee, like 20%.

Try these options: 1) Appeal to your insurance company. Pretty much all carriers have written appeal methods. Explain that you chose a network physician and a network facility and that no choice was available to you for the Anesthesiologist.

2) Make small payments along the way. Send $25 or $50 each month to keep them off your back and to keep them from sending this to collections. Appeals usually take 30-90 days. If the bill goes to collections, your options are much more limited.

3) Contact your insurance agent or your employer's insurance agent if you insurance is through your job. Not everyone has an agent, but if you do, they can help you work through this because they are a third party and can talk to both the provider and the insurance on their terms.

4) If the appeal fails or only goes through for a portion of the charges and you've exhausted all other options, ask to speak to a supervisor at the provider and offer a payoff of something like $0.50 on the dollar of the balance, if you pay within 1 month.

Make them send you it or fax it to you in writing! Ask your agent to do this for you, if you can. Remember, that medical debts, on national average, only collect about $0.19 of every dollar billed to an individual.

No one pays the billed amount for medical services! Insurance companies typically get between 20 and 50 percent discounts with network providers. Medicare is often worse and Medicaid is often much worse. Approach it like someone who is in a bad situation through no fault of your own and you just want to settle the debt. They do, too.

As an agent, I have negotiated anywhere from 5% to 95% for clients.

Answer 2

Unfortunately, it is the patient's responsibility to review their policy guidelines prior to selecting a physician. Upon registering with your insurance company you are provided with a packet which shows your "in-network benefits" as well as your "out-of-network benefits", prior to choosing a physician, you need to contact your insurance company and determine if they are currently participating provider within their network.

Just a general FYI - there are companies out there you can hire, for a reasonably low fee, to help explain your benefits to you and some will also manage your medical bills for you, including fighting your insurance company to pay your claims.

Hope this helps!