Who pays for this doctor visit?
August 4, 2006 5:49 AM   Subscribe

My health insurance company refuses to cover a dr. appt because of a contract dispute of which my dr. claimed to not be a part. Except they were...

I had a dr. appt in early July just after the contract (between Piedmont Healthcare and BCBSGa) ended on 6/30. I spoke with my dr. who said that they were not a part of Piedmont and that all services would indeed be covered as in-network by BCBSGa. I asked them to triple-make sure of this because I could not afford to pay the entire expense out-of-pocket. They assured me I have nothing to worry about.

I saw the doctor again yesterday and there was a sign hanging that said that they are indeed contracted with BCBSGa thru 2010.

Last night I received a statement of benefits from BCBSGa that said that the dr appt will not be covered and when I spoke with the dr.'s office this morning I was told that they were "mistaken" about not being affiliated with Piedmont and they will file a continuation of benefits claim but that I should be prepared to suck it up and cut them a check for the full amount.

I don't understand how this happened. Should I have gotten certain things in writing? Would that even have helped me? Was I deceived or just stupid? Is there anything I can do to not have to pay for this?
posted by superkim to Health & Fitness (9 answers total)
The first thing I would do would be to talk to your actual doctor - not just someone in the office - and explain what happened. Since you received the assurance from him, he may consider majorly reducing or even completely waiving the fees. I suspect you'll have better luck dealing with him than with your insurance company.
posted by ferociouskitty at 6:05 AM on August 4, 2006

Go in, take a picture of the sign in their office, and talk to them again.

As a general legal matter, you should not be deceived into a business transaction that you wouldn't otherwise have entered into. Your doctor's repeated assurances that they were part of X network is something that you should be able to reasonably rely upon.

The equitable solution would be for the doctor to reduce his fees substantially to whatever you might normally pay for a COVERED office visit.

These situations can get ugly (as both sides refuse to help and just insist you pay large sums of money). Put on your happiest face, be prepared to argue with both the doctor and your insurance provider. Doctor's fees are, regardless of what they might say, very negotiable. The same procedure received by an poor, insuranceless person and a wealthy, insured person will be charged vastly different amounts, and this happens every day. You should approach the doctor, describe the situation, and ask firmly and politely for a *substantial* reduction in the charges.
posted by jellicle at 6:07 AM on August 4, 2006

Call BCBS and ask why the services weren't covered (or check to see if it's listed on your EOB). It may be a coincidence that the denial happened while the Piedmont/BCBS fiasco went down. There are plenty of bullshit reasons for insurance to deny a claim besides seeing a doctor out of network. (For example, if it was a physical and it's been less than a full year than your last checkup, or you were seen for a preexisting condition, or your diagnosis you were seen for was one your insurance plan won't cover (alopecia, obesity, depression) even though they're real problems.) These denials can also be appealed, but first make sure you're clear on why BCBS isn't paying.

Or this may be part of the whole July Piedmont debacle. Is your doc part of the Piedmont Physicians Group listed here. Maybe he has privilidges at a Piedmont hospital, but isn't a Piedmont doc, and that's where the mixup occured. It seems as if PPG docs would only have a contract w/BCBS until 2009 according to the August 3rd press release, not 2010. If it turns they told you they had a contract w/BCBS in July but in fact they didn't, then just politely raise hell about the fact that you were told as such. Talk to someone in charge, though. Your doctor, or perhaps the office manager.

Good luck!
posted by neda at 6:18 AM on August 4, 2006

That is very weird. Often in contracting disputes like this, doctor's offices will tell you something like, "Negotiations are ongoing between ABC Insurer and XYZ Physician Group of which I'm a member. We can't assure you that any services will be covered after [X date] through ABC Insurer even though 99% of the time a deal is eventually reached." That would be the responsible thing to do.

If I had to guess, I'd say this doctor decided to contract on the sly individually with BCBS of Georgia and Piedmont told him to read his contract more carefully and that was the end of that.

If this were me, I'd send a letter detailing the dealings you've had with the office along with any co-pay you might owe (if you didn't pay it at the scene of the crime) saying that you understand the service now to be paid in full. Copy your Better Business Bureau and "Fraud Department, Georgia Division of Insurance." I'd expect that would make this go away.

Obviously, BCBS of GA is not going to help you out here, but if you're insured through an employer, now would be the time to explain the situation to them and ask for help.
posted by MarkAnd at 6:29 AM on August 4, 2006

I have received lots of letters from both BCBSGA and my ob.gyn, who is in fact affliated with Piedmont. In one of their letters they said something about coming up with a comprimise, so perhaps you can talk to the doctor, rather than the office staff and see if you can pay a reduced amount or get the charge dropped. It is a bad situation. (I have to find a new doctor pronto to get my depo shot or just pay for it at the doctor)
posted by stormygrey at 6:49 AM on August 4, 2006

If I recall correctly, I specifically heard that pregnant women were getting a pass to continue seeing their OB during the whole thing. For regular office visits for regular non-pregnant people, I would think not. (IE, your specialist provider who is a gastrointerologist and he's been treating your Crohn's for a year - ok, maybe that will work out but not just being sick and going to your PCP. But what I heard was *specifically* pregnant women.)
posted by Medieval Maven at 10:06 AM on August 4, 2006

As a general legal matter, you should not be deceived into a business transaction that you wouldn't otherwise have entered into. Your doctor's repeated assurances that they were part of X network is something that you should be able to reasonably rely upon.

While I completely agree on the "should" it's unfortunate that the way things should be doesn't always enter into such matters. Odds are good that when superkim first went to this office she filled out some intake papers which included an agreement that she is ultimately responsible for settling the account, not the insurance company. In ten years and about 8 physicians/specialists I have not once been to one who didn't have this boilerplate as part of their "new patient" paperwork.

That said, were I you I'd do two things. One, look up the policies and processes for getting reimbursed for out-of-network physician visits. Hopefully it won't get to that but if you can't afford to pay for the visit - and you shouldn't have to - then be prepared to minimize the pain.

Two, draft a letter to your doctor detailing what's happened here.

"On date X I saw Dr Y for procedure Z. At that time I raised the question of insurance coverage Q and was assured by Dr Y that blah blah. I paid the expected copayment of $P with the expectation that the remainder of the account would be settled by my insurance, as indicated by Dr Y.

On date R I received notification from my insurance company that blah blah blah. At that time I spoke to person S who contradicted Dr Y's prior assurance. Person S stated paperwork blah blah would be filed blah blah."

then the juice:

"While I recognize that business relationships change over time, I went forward with the visit only because of the verbal promise from Dr Y that I would not be personally responsible for the visit. Had I been informed accurately I would have canceled the visit and switched to an in-network doctor. I am not willing to shoulder an expense for which I specifically carry health insurance and which I was told by your office that I would not be personally responsible for. Please have someone contact me to discuss how we can come to a mutually agreeable arrangement of this unpleasant situation."

And I'd send it return receipt registered mail.

I don't know that it's going to do you any good, as I said. You've probably committed to pay this and if they want to be hardasses they'll just send you a few bills before they pass it over to a collection agency. At that point you could challenge the debt and demand validation - there's a lot of game to play there if you want to invest the time - but in the end they have the law on their side (assuming you signed such an agreement). At the very least you can show that you're not going to just roll over by sending this letter and it could be useful as a memorialized conversation if you have to end up in court.

Hopefully they'll be willing to lower or waive the fee, but the former is more likely than the latter. If you can find out what percentage your insurance company will let you submit for reimbursal for an out-of-network physician you can propose that amount as a compromise.
posted by phearlez at 1:56 PM on August 4, 2006

aside to Stormygrey: according to this page (check out the Aug 3 pdf's), the matter has been resolved as of yesterday. Piedmont docs are back in network effective August 1st, so you should be able to get your depo.
posted by neda at 5:48 PM on August 4, 2006

Thank you all, I feel much better about the situation and am now feeling well-equipped to handle this.
posted by superkim at 6:35 AM on August 7, 2006

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