"In-network" means "out-of-network"? What a country!

February 20, 2015 7:41 PM

Unbeknownst to me, my in-network-doctor sent my labs out-of-network. I just got the bill :( Now what?

Without any prior notification, my in-network doctor sent my biopsy to be analyzed by an out-of-network laboratory. Now the lab has dinged me with a big out-of-pocket medical bill ($500).

Who do I talk to first / what's my order of operations to see if I have any recourse (at best) or negotiate a lower bill (at worst)?

1 UnitedHealthcare
2 Doctor's office
3 Lab

Bonus points if you provide a script or magic words or phrases that could help in these conversations.

I'm a Canadian in the US and was pretty smug that I understood the in/out of network thing in American health insurance. Now I'm gobsmacked that its remotely cool for an in-network doctor to send tests to an OUT-of-network lab.

Thank you mefites!

posted by kitkatcathy to Grab Bag (15 answers total)

Ask the doctors office if they will send a thing to the insurance company asking time to treat it like in-network for reasons. This works shockingly often. Keep in mind taut American insurance "rules" are more like guidelines. Guidelines made to be broken. Trick is to know how to get away with it.
posted by fshgrl at 7:48 PM on February 20, 2015 [2 favorites]

FWIW, doctors aren't necessarily aware of which other providers and labs are in-network for any of the many insurers they work with. It can even vary between different policies offered by the same insurance company. It's a crazy mess.

Fshgrl is right about asking your doctor to plead your case with your insurer. It can't hurt matters and just might get the amount lowered a bit.
posted by Thorzdad at 7:55 PM on February 20, 2015 [6 favorites]

This JUST happened to me. If you are 100% sure that you have a bill and not just an appeal, I would simultaneously talk to the doctor's office and appeal the bill.
posted by roomthreeseventeen at 8:00 PM on February 20, 2015 [1 favorite]

I''ve had this same thing happen with Humana, I protested the charge as I had no control over what happened when my In-network doc sent my labwork to an out of network lab. Humana agreed with me and changed the charge to in-network.
Which was all a bit confusing because the lab in question *is* in network on other Humana plans in this area.
posted by rudd135 at 8:03 PM on February 20, 2015 [1 favorite]

I've had luck calling the insurance company and letting them know I had no possible way of choosing an in-network provider, because I wasn't in control of that decision. The person on the phone did some sort of computer magic and suddenly the bill was totally covered.
posted by jaguar at 8:46 PM on February 20, 2015 [3 favorites]

Based on past experience working for an HMO, push the "I did not request that this be sent out of network, I did not consent to this being sent out of network, and I should not be charged for this having been sent out of network" issue.
posted by Lexica at 8:55 PM on February 20, 2015 [19 favorites]

I had surgery nearly a year ago in an in-network facility with in-network doctor, etc.

But the anesthesiologist was not in-network. Insurance paid some token amount. The anesthesiologist office contested it, then asked me to call them, which I did a few times. Insurance paid a little more. Anesthesiologist kept bothering insurance and I did too.

Eventually, nearly a year later, insurance paid the rest of the bill.

So the key is to state that you were not given a choice and that you want them to pay the full amount. Oh, and don't give up.

Insurance will drag their feet, send you various final statements, and generally be a giant pain in hopes you will give up.

There are a lot of games that go on between those providing health care and the insurance companies in The US. It is completely insane and broken.
posted by DrumsIntheDeep at 10:02 PM on February 20, 2015 [4 favorites]

It may be helpful to remember: The lab deserves to be paid. They did the work, they should be paid. You should not have to pay out of pocket, however. So your goal is to get your insurance company to pay the lab.

Which they will do. There is certainly some sort of "Override our in-network restrictions" checkbox on their forms, but they need to be persuaded to check it. It is likely you can persuade them yourself; if you can't, ask the doctor's office to do so. (But be aware that the doctor's office has much less incentive to do so, other than maintaining your goodwill, which may or may not be persuasive depending on whether you're a regular patient.)
posted by jaguar at 10:08 PM on February 20, 2015

One thing that may work is to submit the bill to your insurer to pay whatever portion they WILL pay, and then to negotiate the difference with the lab separately.

Also, if you have an HSA, you can pay with your card and the total amount should count towards your deductible.

Call your insurer and see what your options are.
posted by Ruthless Bunny at 6:08 AM on February 21, 2015

So this is called balance billing and it's a thing. Most insurers have a process, though, by which you can appeal an out-of-network provider's balance bill if you had no choice over that provider. (Common circumstances include ER care, maternity care, and the like.) It doesn't always work, but that is your first step -- call your insurer and find out what the appeal process is and get that started. If that doesn't work (if the insurer denies the appeal), then you go to the other options (talking to the lab, etc.).
posted by devinemissk at 6:48 AM on February 21, 2015

Are you 100% sure it's out-of-network? I was recently mailed a bill that treated an in-network provider as though they were out-of-network. I double-checked, called, and they told the claim was processed as out-of-network incorrectly, switched it to in-network, and paid up in full.

You can usually find lists of in-network providers on your insurer's website if you want to check. I hope that's all it is-- it was a nervewracking bill to get but an easy thing to fix!
posted by WidgetAlley at 7:17 AM on February 21, 2015

I also have United Healthcare, and found them extremely helpful last week when I noticed a charge for a routine exam on a bill from my doctor's office. It was an error, and they got it cleared up right away. They also helped me get some lab work recoded (had to request from the dr.) so that it would be covered. Give them a call and see what can be done.
posted by Marie Mon Dieu at 9:09 AM on February 21, 2015

Yes, the lab deserves to be paid. I might note that the negotiated fee (between the insurance company and the lab) for In-network lab work that I had done was less than $100. The out of network charge - for the same thing - was over $400.

I needed an MRI some years back. The insurance company kept insisting it was not medically necessary, they would not pay. The un-negotiated fee for the MRI was a bit over $2000. If the insurance co. would authorize it, it would cost me $800, which would be towards me meeting my deductable, the ins. company actually paid nothing, just got me the reduced fee.

I finally got so frustrated I called the Imaging Center that did the MRI's and asked "How much if I walk in with cash?" - Answer: $800.

IMHO it is a racket. Fine enough if you can price/negotiate services before hand, but what about a crisis situation - heart attack/stroke/etc? You going to stop and ask to go somewhere else that's in network?
posted by rudd135 at 2:38 PM on February 21, 2015

I crazily just dealt with this recently! Maybe I'm you! PM me if you're still having an issue.
posted by bquarters at 4:43 PM on February 21, 2015

Ugh this happened to me once. The effed up part was that the lab he sent me to *was* in-network, but unbeknownst to me he told them to send one sample out to a lab that wasn't covered! Now at every doctor I go to I write "I do not consent to any tests/procedures that are not covered by my insurance" on all my paperwork.

I'd appeal to the insurer, and have the doctor appeal to the insurer as well. It's possible that the doctor felt that this lab was better than any in-network lab for whatever reason, and they can convince the insurer to pay for it.

If that doesn't work, I'd try to get the doctor's office to pay the lab. It's really their responsibility to choose a lab if at all possible that's in your network. Every time I've had a doctor send me for, for example, blood tests, they'll say "oh you have X insurance, go to Y lab."

If nothing else works, call the lab and explain your situation. Ask if they can write off a portion of the bill to what an insurer's negotiated rate is. Then ask if you can be put on a payment plan where you pay X amount over Y months.
posted by radioamy at 6:32 PM on February 21, 2015