In network MRI at a Medical Center

[Tryingtoripmeoff]

My wife went to a doctor at a medical center for knee pain. They were in her network, and charged her as in network for the xray and the doctors visit. They also ordered an MRI and confirmed they still took her insurance for it and it was in network. Her insurance company is trying to bill it as out of network because it is “a hospital”.  But it was not an emergency room, it was a medical center. They are charging her 1500$ when it clearly says in-network MRI’s are 300$, and even on the claim it says in-network MRI.

First the insurance company tried to tell her it was out of network, and then when she proved it was claimed as “in-network” they transferred her to a manager. She was very rude, and told her “it’s billed as a hospital MRI despite being in-network, and you can fight it, but you won’t win!” That doesn’t make sense to me. She had a referral from the doctor at the same center, was charged as in-network for the doctor and the x-ray at the same medical center, and it was a medical center, not an emergency room. And again, it clearly says “in-network” on the claim. It’s upsetting us, to say the least! Appreciate any help at all as to how to fight this.

[Tryingtoripmeoff]

Long story short, they have the MRI filed as in-network claim, but still charging us like it’s out of network. Everything else at same center has been billed at the in-network price, including an x-ray. A random manager from “Florida Blue” insurance company was very rude and told my wife “she would not win”.

[Michele]

The facility that performed the MRI should be fighting this on your wife's behalf.  They are in network so they would contact the insurance carrier to find out why the claim is being processed incorrectly.  Have you spoken to anyone at the facility?  It's good that you are also advocating, but I would contact the facility ASAP.  They may be doing something from their end.  The other thing you can do is contact your Human Resources department to find out if they can assist.  Your employer hires the insurance company to provide the coverage they choose.

Also, this may fall under ERISA laws as well.  I'm hoping Linda will chime in because she knows ERISA much better than I do.

[PMRNC]

First I'll need some info as there are a couple of different ways to get this taken care of and they would produce positive results.
Florida has balance billing laws but Federal rules apply to group health plans.

1) Is your wife's plan a group health plan under an employer that is not church or govt/state?
2) Was this ER, Primary care, Urgent care?
3) Was the actual hospital/facility billed processed and paid at in network? You said the physician was paid, this was radiology provider billing?

I can give more guidance on the type of appeal/complaint you might have with the above info

[Tryingtoripmeoff]

First I'll need some info as there are a couple of different ways to get this taken care of and they would produce positive results.
Florida has balance billing laws but Federal rules apply to group health plans.

1) Is your wife's plan a group health plan under an employer that is not church or govt/state?

It’s a private employer. We are in South Carolina but her company is headquartered in Florida.

2) Was this ER, Primary care, Urgent care?

It was Conway medical center in Conway, South Carolina.

3) Was the actual hospital/facility billed processed and paid at in network? You said the physician was paid, this was radiology provider billing?

The doctor visit was billed and processed as in-network. So was an x-ray that she ordered. So then she ordered the MRI and it was processed as “in-network” on the claim, but they only paid the out of network amount towards it. For some weird reason.  But everything was done in the same building, and the only issue we are having is with the MRI which is fishy because it is obviously the most expensive thing. I really think her insurance company is trying to rip her off, so I have no idea how to make them do the right thing. A lawyer would be pointless because it would cost just as much.

I can give more guidance on the type of appeal/complaint you might have with the above info

Thank you btw!

[PMRNC]

ERISA applies for your situation so it trumps state law and payer contracts.

This one is pretty simple actually because all the other bills were paid at the network rate.

Step one is to look at your wife's SPD - This is not the same as a carriers benefit payment guide/handbook, etc, this is the actual summary plan description.
Step two - locate the appeals process (WHO you appeal to, WHERE you appeal to and how long you have to appeal)
Step three - Using the appeal process write a letter appealing their decision. Reference the other claims that were paid at the in network rate as well as attaching the EOB showing the reduced rate. (provide those EOB's and put attachments at bottom of letter referencing each one.

If you want to PM me your email address I will be happy to provide you a sample letter you can modify. I've done ERISA appeals for my own health plan and for my clients. You can also email me a copy of your EOB so I can make sure the appeal letter will line up with the benefit. Just cover my butt by blacking out all private info including dates of service. My email is linda@billerswebsite.com

You do not need anything from the MRI / Radiology group nor even the dr for this appeal. Under ERISA this is considered an "Adverse Benefit Determination" since they did not pay the entire fee and you are being balance billed.