I went to a doctor that isn't my HMO doctor and no one noticed until the bill was due. What now?

July 11, 2011 9:55 PM

I unknowingly went to a doctor that is not my primary care physician on my HMO plan. What's the damage going to be? What can I do for the best possible outcome?

I have an HMO insurance plan, COBRA-ed from my former employer. At some point my particular plan was dropped from those accepted by my regular doctor. I was automatically given a new primary care doctor and sent a new card. I was not informed of the change, didn't notice the new doctor name on the card and just stuck it in my wallet.

I went to my old doctor and gave them my new card. They accepted it, took my copay and saw me. I had a pap and routine labs. I received a call today from my doctor saying when they ran my insurance they noticed that they aren't my PPC and that I should call my insurance and get them on as my PPC.

I called my insurance and they let me know that my doctor isn't available on my current plan, although they are on a similar one. I feel really dumb for being oblivious to this change so please, no chastisement for that. What is going to happen now? What are my options here? What's the best way to proceed?

posted by hot little pancake to Health & Fitness (13 answers total)

In my experience, if you call your doctor's office back, and tell them that you're going to be 'self pay,' rather than insured, they will not only give you a discount (paperwork costs money, after all), but they will also put you on a payment plan. Play dumb on the phone, explaining that you made a mistake, as that seems to loosen them up, too. You've got nothing to lose.
posted by Gilbert at 10:08 PM on July 11, 2011 [2 favorites]

Do you know if your insurance will cover your labs? Those w/out insurance may be more expensive than the drs office visit.
posted by oneear at 10:14 PM on July 11, 2011

Good point, oneear. Docs will cut your costs, but labs will generally cost what they cost, regardless.
posted by Gilbert at 10:26 PM on July 11, 2011

Yeah, call the doc you saw and tell them what's happening and see if they'll lower their rates for you. For a long time I went to a certain doctor who I loved, even though she was out of my network. The self-pay rates were only a little higher than my usual co-pay, and she sent my labs to an approved lab, so those were covered at the usual rate by my insurance.

Of course part of this depends on if this is someone you just need to see the one time, or if you hope to have an ongoing relationship with this doc. If you're treating some long-term, higher cost issue, I'd just pay cash for that appointment and get back with a doc who is on your plan.
posted by BlahLaLa at 10:27 PM on July 11, 2011

Response by poster: Oneear: That's what I'm most worried about. Does anyone know if labs that would usually be covered under your plan are still covered if they aren't ordered by your primary care doctor? Will the insurance company work with me on this or is it black and white?
posted by hot little pancake at 10:35 PM on July 11, 2011

Best answer: They should accept the lab's bill based on whether or not the lab itself is an accepted provider, not by who ordered their services. Should.

As long as a provider is in their network, they should work with you on any billing issues associated with those providers.
posted by batmonkey at 11:53 PM on July 11, 2011 [1 favorite]

I'd check with the insurer. Sometimes the difference between in-network and out-of-network is just a slightly higher copay. Depends on your plan.
posted by lakeroon at 4:27 AM on July 12, 2011

Best answer: Even if you have to do self-pay, you're only looking at a few hundred bucks at the absolute most. The office visit should be less than a hundred, and pap smears/bloodwork aren't terribly expensive. You can probably negotiate something with the hospital, but the absolute worst-case scenario isn't the end of the world.
posted by valkyryn at 5:09 AM on July 12, 2011

Don't feel dumb---this is exactly the kind of complication the US health system begets. "Logic" and neoliberals might say "Well, you received a notice...you should've..." but add that one legally worded notice to the myriad of notices, rules, responsibilities we all attend to on a daily basis and "should'ves" quickly disappear.

Call your insurer again, if you can stomach it, and ask them if the labs will be covered. Ask for a payment plan from your physician, and then consider changing physicians---you may not have to simply see the one on your card...you may be able to choose a different one that's in their network.
posted by vitabellosi at 5:09 AM on July 12, 2011 [1 favorite]

You should have a statement of benefits that clearly states what costs are covered for out-of-network doctors. In some cases, it'll be a higher copay, or the insurance will pay a certain percentage of the doctor's cost.

If your insurance does cover out-of-network doctors, odds are that the expense will be great enough to deter you from making this mistake again, but not great enough to cause long-term financial distress.

Don't go "self-pay" until you're absolutely certain that the insurance company will not cover the visit itself. Also, fight tooth-and-nail to get your labs covered; your odds of success there are likely going to be a lot higher.
posted by schmod at 6:59 AM on July 12, 2011

Call your new doctor and ask for a referral to your old one. They can do this retroactively. I think referred doctors don't have to be in the plan, but I am not certain of it.
posted by Kirth Gerson at 8:40 AM on July 12, 2011

I had a similar situation happen to me. I did not run a check before an appointment only to find the doctor had been dropped by my plan. I did pay the out of network bill which was approximately $300. I was apart of a PPO at the time. I considered it my "stupid tax" and now run a check on my insurance plan's website before every appointment.

I agree with what Gilbert says, but I will try to offer another suggestion:

Have you looked closer at the dates? When did they specifically drop the doctor? Is it possible you went to the appointment before the doctor was dropped?

This suggestion is probably unlikely, but you may be able to actually find a compassionate person at the insurance company by saying, "Look, this doctor was always in my plan. I don't have any documentation from you indicating there was a change." Granted they sent you a new card, but was there a letter indicating the change? If they say there was ask - "I didn't get that letter, can you resend it to me?" You will probably find they are unable to as it probably never existed. This may press to the customer service rep, that you know of their intention to play dirty and not make you aware of the change. Hint you will report them to your state's insurance board for their tactics.

Good Luck.
posted by BuffaloChickenWing at 9:22 AM on July 12, 2011

Call your new doctor and ask for a referral to your old one. They can do this retroactively. I think referred doctors don't have to be in the plan, but I am not certain of it.

This depends entirely on the terms of the plan.
posted by Pax at 11:55 AM on July 14, 2011