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How does being charged OON for an appointment go when you were informed until after the appt.

dont pay the bill
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pay the bill
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Author Topic: being charged OON for my daughters 3 month check up b/c they were neg. contract  (Read 2901 times)

dianab

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i have received a bill for my dts 3 month check up for 164.24.  I paid a copay of 35.00 and it was excepted.  My bill should have been 0 b/c part of my ins. plan is free well baby visists.(shots)  I got the bill and called and they said I should have been notified that they were OON.  I was not notified by that appt.  I was notified approx. in end of Jan beg. of Feb when they were going to reschedule her 6 month check up to another location(30 more mins. out of my way) so it would be in Network.  I said no, swithced her pediatrician to local MD that was in network and she saw them until i was notified that previous Md was back in network.  I have explained this to them and their billing but they say all they can do is give me a 30% discount.  How is this, when I was not informed until her next appointment.  What do you think about them excepting my copay at that appointment.  Please help me with this, I can not pay a 164.00 bill especially when I pay my insu. premiums to help with bills.

PMRNC

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It's technically your responsibility to make sure you see a provider in - network.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

dianab

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Yes Ma'am, I understand that.  For the past 3 years though(they are my 3 year old daughterd md also) they have been in network and I have never had any problem like this, So.... I would not think to ask are they in network b/c that's where I have always gone.  Could I get some advice on this.  Thanks so much for your input.

dianab

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 ??? I just received call from office manager at pediatrician office.  She stated that they took my copay b/c they didn't know i was out of network either?????????What???
How was I supposed to know then.  I reinforced this with her and she still tried to offer just a discount.  I feel like I am going to blow.  MY back is against the wall.  Please help ???

PMRNC

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You need to call your insurance carrier and find out first for sure if this doctor is or is not in your network. If they are not, then again, technically it's still your responsibility to have made sure of this.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

dianab

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They are in network and have been since my 3 year old was born.  They were "negotiating" their contract w/ BCBS at this time.  I wasn't aware of this, therefore, when she went to her appointment, I was "OON"

blhoffman

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May I ask who is the insurer? What state?

Pay_My_Claims

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uuugh @ BCBS

PMRNC

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Without being privy to their contract or terms with BCBS, you are sort of stuck, if BCBS says they were NOT in network at the time of service, then the balance is your responsibility. What is the carrier telling you as far as their participation stats at the time your services were rendered?
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

blhoffman

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My opinion would be to call the insurer and advise them that the provider was par for the last several years. When you went to the appt., you were not made aware of the contract neg. taking place or there was a recent change in their status. This same provider is now par again with the insurer. You would like a pay and educate done on this claim because you feel you should not be responsible for the payment of this claim, as it was not common knowledge of their status before the appt.

If they state you can't have it done and you have to appeal, then I would most definitely appeal. I have to say it again, ALWAYS appeal.

PMRNC

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I didn't catch where they were par again, but something else comes to mind when your dealing with BCBS, their contracts USUALLY spell out there is a 6 mos to 1 year (I've seen both) for them to be dropped, if they were in contract negotiations, they should not have been dropped unless the span was within one of those time frames (doubting that) With that said and they are insisting they were or ARE OON are you positive they ever re-joined? But you have to call the carrier for that information.  Also many of BCBS's contracts require the carrier to notify the patient. That's another thing you can mention.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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My opinion would be to call the insurer and advise them that the provider was par for the last several years. When you went to the appt., you were not made aware of the contract neg. taking place or there was a recent change in their status. This same provider is now par again with the insurer. You would like a pay and educate done on this claim because you feel you should not be responsible for the payment of this claim, as it was not common knowledge of their status before the appt.

If they state you can't have it done and you have to appeal, then I would most definitely appeal. I have to say it again, ALWAYS appeal.

Exactly.  As the patient, your contract is with your insurance company.  If the insurance company had dropped the provider you would still be responsible for the bill.  You got a raw deal only because of the run around you received from the doctor's office, and they may not have been aware of what was happening between the provider and the insurance company.  Heck, the provider may not even have know what was going on!

Sorry for your trouble, but it's best for you to work with the insurance company to get the in-net/out-of-net dates and talk to someone there to determine your financial liability. 

Pay_My_Claims

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I didn't catch where they were par again, but something else comes to mind when your dealing with BCBS, their contracts USUALLY spell out there is a 6 mos to 1 year (I've seen both) for them to be dropped, if they were in contract negotiations, they should not have been dropped unless the span was within one of those time frames (doubting that) With that said and they are insisting they were or ARE OON are you positive they ever re-joined? But you have to call the carrier for that information.  Also many of BCBS's contracts require the carrier to notify the patient. That's another thing you can mention.

So True Linda in regards to providers network status....some don't keep up with their credentialing. don't know if this happened in this situation, but great point!!

blhoffman

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Quote
I was not notified by that appt.  I was notified approx. in end of Jan beg. of Feb when they were going to reschedule her 6 month check up to another location(30 more mins. out of my way) so it would be in Network.  I said no, swithced her pediatrician to local MD that was in network and she saw them until i was notified that previous Md was back in network.

I would make sure all this information was in the appeal if you can't get them to send the claim back for reprocessing at BCBS.

I agree with Linda, when you call the carrier, get the dates they were in network and out of network, and then back in network. You can put that in the appeal, if again they won't reprocess for you.