USA insurance question
September 6, 2022 11:05 AM Subscribe
How do I handle a large medical bill, which seems to come down to a physical therapist being considered out of network because I was serviced at location A instead of Location B?
Went to a doctor and got recommended for physical therapy. This doctor recommended me to his facility's physical therapy unit. This facility is one of those mini centers that has a lot of things in-house and has several such centers in my county and surrounding counties. For ease of explanation, we'll call the location I went to for the therapy this:
Generic Health Center
John Doe (physical therapist)
1234 Generic Drive
I did not have to pay a co-pay when I went to this facility.
Months later, I've received a huge medical bill and when I called my insurance about it, turns out that physical therapist at this location is considered out of network but the same physical therapist, at a different location, is considered in network. Both locations are under the "brand name" of Generic Health Center.
So the location I went to, listed above, is not considered in network. Instead, if I had gone to this location:
Generic Health Center
John Doe (physical therapist)
5678 Notspecial Road
To see the same physical therapist and get the same treatment, that would have been considered in-network.
This was all explained to me by the person on the line when I called my insurance company.
Can anyone recommend a way to "fix" this so that insurance does cover the services/considers them in network? The locations are only 7 miles apart and in the same county
Went to a doctor and got recommended for physical therapy. This doctor recommended me to his facility's physical therapy unit. This facility is one of those mini centers that has a lot of things in-house and has several such centers in my county and surrounding counties. For ease of explanation, we'll call the location I went to for the therapy this:
Generic Health Center
John Doe (physical therapist)
1234 Generic Drive
I did not have to pay a co-pay when I went to this facility.
Months later, I've received a huge medical bill and when I called my insurance about it, turns out that physical therapist at this location is considered out of network but the same physical therapist, at a different location, is considered in network. Both locations are under the "brand name" of Generic Health Center.
So the location I went to, listed above, is not considered in network. Instead, if I had gone to this location:
Generic Health Center
John Doe (physical therapist)
5678 Notspecial Road
To see the same physical therapist and get the same treatment, that would have been considered in-network.
This was all explained to me by the person on the line when I called my insurance company.
Can anyone recommend a way to "fix" this so that insurance does cover the services/considers them in network? The locations are only 7 miles apart and in the same county
Best answer: I take it you are in the U.S. It would be helpful to know what state you are in as states may have helpful laws regarding this.
Effective 1/1/2022, however, the Federal No Surprises Act includes some consumer protections that may assist you. I think that the provider should have given you a "good faith estimate" of its charges, and should have informed you that you were being treated at an out of network facility. They should have asked you to sign a notice and consent to be treated at the out of network location.
I'd do a couple of things. First, arm yourself with the consumer rights information at the above link. Then contact the facility, as that is who is likely at fault here, and advise them that you would like them to accept the in-network payment as payment in full for their services. At the same time, reach out to your insurance carrier with the same information and request that they cover the treatments at the in-network benefit level. If either of them fails to comply, you have the right to submit a complaint to CMS.
Memail me if you'd like assistance on this.
posted by gauche at 11:29 AM on September 6, 2022 [7 favorites]
Effective 1/1/2022, however, the Federal No Surprises Act includes some consumer protections that may assist you. I think that the provider should have given you a "good faith estimate" of its charges, and should have informed you that you were being treated at an out of network facility. They should have asked you to sign a notice and consent to be treated at the out of network location.
I'd do a couple of things. First, arm yourself with the consumer rights information at the above link. Then contact the facility, as that is who is likely at fault here, and advise them that you would like them to accept the in-network payment as payment in full for their services. At the same time, reach out to your insurance carrier with the same information and request that they cover the treatments at the in-network benefit level. If either of them fails to comply, you have the right to submit a complaint to CMS.
Memail me if you'd like assistance on this.
posted by gauche at 11:29 AM on September 6, 2022 [7 favorites]
Seconding advice by gauche.
I had this same situation recently, except I was warned. When I had to start PT after hand surgery, I was informed that the therapy location I was already standing in--inside a hospital and next to my hand surgeon's office--was out of network for my otherwise very good insurance. But a second location 4 miles away was in network. I learned that day that insurance doesn't like to cover PT that's inside a hospital because it's a lot more expensive than PT in free-standing buildings--even if they're on the campus of a hospital. This is probably what's happening with your situation too. But they should have warned you. And thanks to the No Surprises Act, they may in fact have been legally required to warn you.
posted by ImproviseOrDie at 1:53 PM on September 6, 2022
I had this same situation recently, except I was warned. When I had to start PT after hand surgery, I was informed that the therapy location I was already standing in--inside a hospital and next to my hand surgeon's office--was out of network for my otherwise very good insurance. But a second location 4 miles away was in network. I learned that day that insurance doesn't like to cover PT that's inside a hospital because it's a lot more expensive than PT in free-standing buildings--even if they're on the campus of a hospital. This is probably what's happening with your situation too. But they should have warned you. And thanks to the No Surprises Act, they may in fact have been legally required to warn you.
posted by ImproviseOrDie at 1:53 PM on September 6, 2022
Response by poster: So I telephoned the provider of the Physical Therapy, let's call them ABC Medical Group of Georgia (USA). They informed me that the medical bills were denied by insurance (DEF Insurance of Georgia) as out of network.
I telephoned DEF Insurance again and they agreed they provider was out of network. They did say I could dispute the bill and gave me a fax number. I mentioned the out vs in network charge (and I'm ok with paying the in network charge) and the Federal No Surprise Act and was told to mention that in the dispute later.
Does anyone have any other advice on how to move forward? This feels like a run around, but have no problem faxing off an appeal.
posted by clocksock at 11:30 AM on September 8, 2022
I telephoned DEF Insurance again and they agreed they provider was out of network. They did say I could dispute the bill and gave me a fax number. I mentioned the out vs in network charge (and I'm ok with paying the in network charge) and the Federal No Surprise Act and was told to mention that in the dispute later.
Does anyone have any other advice on how to move forward? This feels like a run around, but have no problem faxing off an appeal.
posted by clocksock at 11:30 AM on September 8, 2022
This is not going to be a very optimistic answer, unfortunately, but might shed some additional light on this shady practice being relatively normal for healthcare overlords. I had a similar situation, which I battled for nearly a year, going all the way up the chain of appeals and grievances within the insurance company. Long story short, my provider told me to get standard blood work, and she recommended a lab. I called both the lab and my insurance prior to my appt -- both said "yes" we are in network. I proceeded with the appt. I received a bill for more than $1000 for routine bloodwork and was shocked, as my SOB showed it should have just been a straightforward $40 copay. Through various conversations, complaints, and supposed efforts on behalf of the facility and the insurance company, I learned that although the lab was not located IN a hospital, it was operated by A hospital. (How could I have know this? I could not have.) And apparently, with my insurance plan, a hospital run lab is subject to deductible and coinsurance, rather than an independent lab, which would have just been the $40 copay. Outrageous! I complained to high heaven about the scamminess of this -- particularly that the lab was not located in a hospital nor identified as a hospital laboratory -- but all the appeals and grievances were denied because they were simply operating within the the terms of my plan.
I was finally told that my only possible recourse was to request financial assistance for the bill from the provider; otherwise they'd send it to collections. Like I said -- I spent a year on this struggle and ultimately gave up and paid the bonkers bill. I spoke to a friend who is an exec in healthcare, and she said that I could complain to regulating agencies (Dept of Consumer Affairs, Office of Insurance, etc -- depends on the state) but that any positive outcomes would be slow in coming and probably not impact me, but rather other people down the line.
So, what to do? Document every conversation. Seek financial assistance from the provider if possible to reduce the bill, complain to the state regulating agencies, and file all the grievances/appeals you can -- all the while not paying. As long as you keep everyone in the loop that you're trying to work this out between the agencies, they'll not send it to collections for quite some time. I hope you have better luck than I do!
posted by luzdeluna at 5:25 PM on September 8, 2022
I was finally told that my only possible recourse was to request financial assistance for the bill from the provider; otherwise they'd send it to collections. Like I said -- I spent a year on this struggle and ultimately gave up and paid the bonkers bill. I spoke to a friend who is an exec in healthcare, and she said that I could complain to regulating agencies (Dept of Consumer Affairs, Office of Insurance, etc -- depends on the state) but that any positive outcomes would be slow in coming and probably not impact me, but rather other people down the line.
So, what to do? Document every conversation. Seek financial assistance from the provider if possible to reduce the bill, complain to the state regulating agencies, and file all the grievances/appeals you can -- all the while not paying. As long as you keep everyone in the loop that you're trying to work this out between the agencies, they'll not send it to collections for quite some time. I hope you have better luck than I do!
posted by luzdeluna at 5:25 PM on September 8, 2022
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I'd call the office manager at the provider and see if the second location will submit a bill to your insurance for it. They ought to have an interest in working with you because they want to get paid.
posted by jquinby at 11:23 AM on September 6, 2022 [2 favorites]