Life & Health Insurance/Out of Network HMO


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.

Good Morning:

It is your responsibility to stay in-network as you know, and unfortunately your situation is the most common complaint when health insurance policies go wrong. You would think that your PCP would know not to refer you to an out of network provider, but they have so many insurance companies to deal with it, and will have no idea which insurance companies the specialist is contracted with at that time. Possibly the specialist was contracted with your insurance company, but recently stopped accepting your plan, your PCP having no way of knowing this. Imagine all the different scenarios in which things can change and you will see why, ultimately, it is your responsibility to double check that your providers are in-network.

That said, there are things you can do that may reduce the amount owed. Request reconsideration of this bill with your insurance carrier. HMO's have a different set of rules and laws that the providers and those enrolled must abide than those with PPO's. As an HMO participant you will be able to challenge this bill at several administrative levels.
Also, contact the Texas Department of Insurance, ( asking that they assist you in resolving this issue. Again, this is a top complaint from consumers relating to their health insurance policies, so your local Department of Insurance should be able to assist you.
My educated guess is that this will be resolved with an outcome all those involved can live with, but certainly you must take immediate action. This is not going to resolve itself unfortunately.

Thank you.

Mike Higgins

Life & Health Insurance

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Michael Higgins


All questions pertaining to health insurance, whether group, individual/family, student, child-only, COBRA, HIPAA, Portability, dental. No expert knowledge in areas such as life insurance, disability, workman's compensation, auto, etc.


34 years as owner of health insurance agency, primarily dealing with Blue Cross Blue Shield of Arizona.

College, Business Administration.

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