Helping to prevent pitfalls for others

[ConsumerAdvocate]

What is the name of your state? California

For an elective procedure, I confirmed in advance with the facility's representative that the doctors and facility are in-network. I also confirmed on the insurance website that both facility and doctor are in-network. Still, I received a surprise medical bill from the doctor.

Contacting the insurance company, the representative said the facility's location is not listed on the doctor's page, that only locations listed on that page are approved as in-network for that doctor's services.

I asked the insurance representative, "Shouldn't the doctor's page on the insurance company's website say "IN-NETWORK ONLY AT THESE LOCATIONS"? The representative said she has no control over what is posted on the website. I asked to speak with a supervisor.

Ultimately, the insurance company agreed to reimburse the doctor in full for the full uninsured rate, about four times the in-network rate. From my understanding, insurance companies welcome all justifiable over-billings since they can raise their premiums commensurately to justifiably hire more agreeable representatives. Am I correct here, or being a cynic?

What would you recommend I do, if anything, or should I count my blessings and forget about it? Thank you.

 

[quincy]

What is the name of your state? California

For an elective procedure, I confirmed in advance with the facility's representative that the doctors and facility are in-network. I also confirmed on the insurance website that both facility and doctor are in-network. Still, I received a surprise medical bill from the doctor.

Contacting the insurance company, the representative said the facility's location is not listed on the doctor's page, that only locations listed on that page are approved as in-network for that doctor's services.

I asked the insurance representative, "Shouldn't the doctor's page on the insurance company's website say "IN-NETWORK ONLY AT THESE LOCATIONS"? The representative said she has no control over what is posted on the website. I asked to speak with a supervisor.

Ultimately, the insurance company agreed to reimburse the doctor in full for the full uninsured rate, about four times the in-network rate. From my understanding, insurance companies welcome all justifiable over-billings since they can raise their premiums commensurately to justifiably hire more agreeable representatives. Am I correct here, or being a cynic?

What would you recommend I do, if anything, or should I count my blessings and forget about it? Thank you.

ConsumerAdvocate, the FreeAdvice forum is not a discussion forum. Instead, we assist posters with their current legal issues.

You, fortunately, already have had the billing issue with your insurance company resolved. There is nothing for us to help you with.

You can “count your blessings” and/or you could try to locate a site on the Internet that welcomes discussion and where you can come up with ways to “prevent pitfalls for others.”

(as a note: IF you find such a site, please do NOT post a link to it here. Thanks)

 

[ConsumerAdvocate]

Re: we assist posters with their current legal issues.

Does nobody here handle class action law? Your loss if you don't want to explore and help solve the big issues.

Thank you for your time.

 

[cbg]

Personally, if I saw that some but not all doctor's locations were listed on the insurance page, I"d want to know why the other locations weren't listed and investigate further. You are damned lucky that the insurance carrier agreed to make payment. You dodged a very big bullet here, my friend; they could quite legally have told you to pound sand and you wouldn't have had a legal leg to stand on.

 

[quincy]

Re: we assist posters with their current legal issues.

Does nobody here handle class action law? Your loss if you don't want to explore and help solve the big issues.

Thank you for your time.

The terms and conditions of this forum prohibit the posting of commercial links and commercial messages.

Many of the volunteers on this forum “explore and help solve big issues” in our lives off the internet, by the way. What we can offer on this forum, however, is limited in scope. A poster will need to seek out a lawyer in their own jurisdiction for legal advice specific to their needs.

Good luck in your quest to help consumers.

 

[ConsumerAdvocate]

Personally, if I saw that some but not all doctor's locations were listed on the insurance page, I"d want to know why the other locations weren't listed and investigate further. You are damned lucky that the insurance carrier agreed to make payment. You dodged a very big bullet here, my friend; they could quite legally have told you to pound sand and you wouldn't have had a legal leg to stand on.

I appreciate your opinion. I didn't even know to look for locations. I presumed, because the doctor was advertised on the insurance company's website, that he is in-network and assumed the locations listed were advertising for the benefit of his proximity.

I wonder what percentage of lay people like myself know better the standard of practice? And is the standard defined by the letter of the law which remains hidden in profitable obscurity, or the spirit/intent of it, in agreement with what the lay consumer would intuitively discern from the listing of locations without any statement saying, "Doctors are only in-network at listed locations"?

Thanks you for your thoughts and time. I appreciate it.

 

[ConsumerAdvocate]

The terms and conditions of this forum prohibit the posting of commercial links and commercial messages.

By my seeking general advice you've come to presume that I am selling something? Baffling. Please tell me how I gave you that impression. Thank you.

 

[Just Blue]

By my seeking general advice you've come to presume that I am selling something? Baffling. Please tell me how I gave you that impression. Thank you.

sigh....Quincy was letting you know that attorney's are not allowed to troll for clients on this site. He said that because you mentioned starting a class action suit.

 

[ConsumerAdvocate]

sigh....Quincy was letting you know that attorney's are not allowed to troll for clients on this site. He said that because you mentioned starting a class action suit.

Sorry for choosing a username that gave anybody the impression of my being a lawyer. I am not.

Having been stung with a surprise medical bill, I want to do my part to help eliminate them. And the suggestion of a potential class action was to see if I could arouse an interest in the off-put discussion.

Thank you.

 

[Just Blue]

Sorry for choosing a username that gave anybody the impression of my being a lawyer. I am not.

Having been stung with a surprise medical bill, I want to do my part to help eliminate them. And the suggestion of a potential class action was to see if I could arouse an interest in the off-put discussion.

Thank you.

I doubt anyone thinks you are an attorney...but this site does not allow it's members to take other members for clients. If you are interested in starting a law suit (and based on your postings I can't imagine what you would sue for), you will need to find an attorney elsewhere. You may wish to call the State Bar and ask for a referral.

Please read the Terms for this site so you have a better idea of it's purpose. The TOS is located at the bottom of this page.

 

[quincy]

... Having been stung with a surprise medical bill, I want to do my part to help eliminate them. ...

I am sorry I misunderstood your purpose in posting to this forum.

If you found the information on the insurance website misleading, you can explore the possibility of filing a false or deceptive advertising complaint with the California Department of Insurance (http://www.insurance.ca.gov/01-consumers/101-help/).

Here are links to the advertising laws:

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=17500

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=790.03.&lawCode=INS

You might find your complaint leads to changes in the insurance website’s wording, which could in turn help consumers like yourself avoid surprise billings in the future.

Good luck.

 

[ConsumerAdvocate]

Please read the Terms for this site so you have a better idea of it's purpose. The TOS is located at the bottom of this page.

"The FreeAdvice Forums are intended to enable consumers to benefit from the experience of other consumers who have faced similar legal issues."

Is not avoiding and extracting one's self from the entrapment pitfall of a surprise medical bill a legal issue? Might FreeAdvice.com welcome the suggestion of adding it as a subforum to Medical and Health Care Malpractice as a way of adding value to the community, building its brand as a valuable contributor of advice and bringing business to its advertisers/sponsors -- the banner at the bottom that says, "Find the Right Lawyer for Your Legal Issue!"?

I would think that doctors who work at in-network facilities should be considered in-network by definition and either they or the facility should cover any surprise medical bills, similar to the annual pro-bono service requirement that lawyers have.

Thank you.

 

[quincy]

"The FreeAdvice Forums are intended to enable consumers to benefit from the experience of other consumers who have faced similar legal issues."

Is not avoiding and extracting one's self from the entrapment pitfall of a surprise medical bill a legal issue? Might FreeAdvice.com welcome the suggestion of adding it as a subforum to Medical and Health Care Malpractice as a way of adding value to the community, building its brand as a valuable contributor of advice and bringing business to its advertisers/sponsors -- the banner at the bottom that says, "Find the Right Lawyer for Your Legal Issue!"?

I would think that doctors who work at in-network facilities should be considered in-network by definition and either they or the facility should cover any surprise medical bills, similar to the annual pro-bono service requirement that lawyers have.

Thank you.

You are misunderstanding the purpose of this forum. We address a poster’s current legal matter. YOU no longer have a current legal matter.

As to providing general legal information that is not connected to a poster’s current legal matter, you can check out the rest of the FreeAdvice site: https://www.freeadvice.com/

If you have suggestions on how to improve the forum, you can submit them to the administrators of FreeAdvice by using the Contact Us link at the bottom of this (and every) page.

Good luck.

 

[cbg]

There are SOME facilities where all the doctors are in-network regardless. These are generally ones where the doctor's are contracted to the facility, which then handles all the insurance arrangements. Often, but not always. these are private facilities with a limited patient base; as an example, I work for a major research university. We have on-campus clinics where students, and employees who have chosen to participate, can get most of their non-hospital care. All doctors are automatically in-network, but you have to have an affiliation with the university to use it. Not all of them are private; the ones who aren't are going to be staff-model HMO's. Kaiser Permanente is an example of a staff model HMO. Anyone can join, but you have to be a member to use the facility.

At other facilities, however, the doctors contract directly with the insurance company individually, separately from the facility itself. The doctors have free choice whether to participate in any given network or not. Believe you me, after 40 years of working in all aspects of employee benefits, I can tell you that the facilities and the insurance carriers would both love it if they could force all the doctors in a particular facility to be in network, but since the doctors are not contracted directly to the facility, they don't have that option.

So when you know that the doctor works out of many locations, and only some of those locations are listed, do not take it for granted that he is in network everywhere. There's a reason only some locations are listed and it should be common sense that if they aren't, you need to find out why instead of making an assumption.

Would it be a good idea for the website to spell out that only the named locations are in network? Sure, since so many people don't bother to read the fine print, it probably would be.

Does failure for them to do so create a legal liability for them to pay a doctor in network when there is no contract in place? Not by a long shot, sport.

 

[ConsumerAdvocate]

I am sorry I misunderstood your purpose in posting to this forum.

If you found the information on the insurance website misleading, you can explore the possibility of filing a false or deceptive advertising complaint with the California Department of Insurance (http://www.insurance.ca.gov/01-consumers/101-help/).

Here are links to the advertising laws:

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=17500

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=790.03.&lawCode=INS

You might find your complaint leads to changes in the insurance website’s wording, which could in turn help consumers like yourself avoid surprise billings in the future.

Good luck.

It takes two to tango and I'm sorry for my part in causing the misunderstanding.

I appreciate the links you provided. Thank you!

Code 790.03.h(7): "Attempting to settle a claim by an insured for less than the amount to which a reasonable person would have believed he or she was entitled by reference to written or printed advertising material accompanying or made part of an application."

Is not the intent/design of the insurance company's website to advertise greater choice of doctors in close proximities to attract members? Is it the duty of a "reasonable person" to look through the fine print and see the omission of the location of an in-network facility? Or is it the duty of the advertiser to make obvious (not just in the fine print) that the doctor is only in-network at the specified locations?

Thanks again.