Life & Health Insurance/Out of Network Bills

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Question
Good day Sir.

I am enrolled in a HMO plan offered by my employer in Texas. I have a designated PCP who refers me to a specialist, as needed. I have been using this plan for over 3 years, this particular PCP for 10 months, with no issues. Recently, a certain medical test had to be performed on me and they referred me to a diagnostic center and the one-time (2 hour) testing was performed at the PCP's office. After 3 months, I find out that this diagnostic center (specialist's office) is not covered in my insurance plan as they are 'out of network' and I am stuck with a $9,000 bill, for what should have otherwise been a $25 co-pay test. It would seem to me that this is a mistake on the part of PCP's office staff, to not have checked if the specialist is in my insurance plan or not, before scheduling them. Also, the specialist should have looked into this, before accepting my (new) case. There are tons of other specialists who are covered under my plan that I should have been referred to for this test, instead of this particular one who seems to perhaps have a 'tie-up' with the PCP.

What are my options at this time? Anything which involve not ruining my credit history, or am I over-reacting? It feels like a bad dream turned nightmare. Please help! God bless.

Answer
Distressed,

Thank you for your question and I am so very sorry you are having these issues.

This is one reason why so many HMOs went the way of the dodo bird.

You have stated every point that people make on this process. The HMO was to sort of "force you" to work in their network of doctors they had already selected. Unfortunately things like this happen all the time and it's where the doctor, the HMO, and the facility do not communicate well. You are right in that you technically should not have been sent to a doctor outside of the HMO, but in playing the other side they look at the HMO as "your responsibility to know". It's not perfect and it's not always making sense, but in the end the process of procedures and being sure the doctor you are sent to is in your network of approved docs is on you and not the physician's office. They will send you where they usually send people. Now, whether it's a good colleague and friend or someone who is on your network is not the job of the doc and his staff to know. Their job is to get you better with the best THEY know and apparently this doctor you were sent to was just that.

The biggest thing that concerns me is that you only found this out 3 months later. Now, the facility you were sent to should have done their homework. However, in these cases you making a call to your provider and verifying is still in essence up to you if you want to avoid the big bill.

Your biggest question is where you go from here. The procedure has been done, you were expecting one thing and the you are getting another. You can call your HMO and ask them their thoughts. You can call the facility and explain the situation and work on a fair and agreeable option to pay. Either way, communication will be the key in this if the facility ever hopes to see a dime of their funds. Many times, if handled correctly, a facility or doctor would consider taking a "pay off" amount that is less than what is being billed. You will have to be professional and kind through the process because I am certain you are not the first person to have this happen.

I wish I could offer more options. The HMO call could prove helpful as well as you got through this. If you approach them as a "partner in the solution" as opposed to telling them they need to pay this or else...you might get farther.

I would be interested in knowing how it all goes. Feel free to contact me again.  

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Gene Ramsay

Expertise

I can answer questions from people regarding health, life, and voluntary insurance. I can also answer certain annuity questions, long-term care, medicare, vision, dental, group products, individual products, and certain carriers. Another area would be general discussion on an individual basis to determine need and help individuals make the right decisions for them. I can also field questions from other insurance providers about carriers I represent so we can do some business together and I am also willing to offer my thoughts on certain issues they may be having with clients/customers, etc.

Experience

My experience comes from helping many people every day handle tough situations in the health, life, and voluntary insurance markets. I do not claim to know it all, but I will always be direct and professional.

Organizations
National Association of Health Underwriters, Alabama Association of Health Underwriters, Birmingham Association of Health Underwriters

Publications
Self Funding Magazine, ezines.com, Birmingham Business Journal, North Jefferson News

Education/Credentials
My educational credentials are holding a health and life insurance license in multiple states.

Awards and Honors
Colonial Life Rookie Sales Award of the Year (2006), Treasurer - Birmingham Association of Health Underwriters (2010), NAHU Region 5 & 6 Leadership Conference Participant (2011), "Benefits Selling" Magazine Reader Council Advisory Board (2011), President Elect - Birmingham Association of Health Underwriters (2011), President (2012-2014), VP of Technology - Alabama Association of Health Underwriters, (2011-Present), NAHU LPRT Soaring Eagle Award Recipient (2013)

Past/Present Clients
I would prefer not to divulge clients without their consent to do so.

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