Getting billed after insurance card info and co-pay is accepted.

[Cntsmom]

Hello I have a question.  My daughter had a cold.  I called a doctors office to see if they accepted my health coverage.  I was told yes and they gave me an appointment for the next day.  When we arrived at the office I filled out the forms, handed my insurance info to the lady at the front desk and paid my co-pay.  About a month later I started receiving bills because my insurance denied the payment because the Doctor was not in my network.  What should I do?

[Michele]

The problem is in the wording.  "Accepting" your insurance and participating with your insurance are two different things.  They may accept your insurance but be out of network.  I would try calling the provider's office to ask if the claim was processed correctly.  There may have been a mistake.  But unfortunately it is important that in the future you ask if they PARTICIPATE with your insurance.  A better thing to do is to check with the insurance carrier to see if the provider is in network.

[Cntsmom]

So because they accepted the insurance and the co-pay I have to pay that bill? Isn't that illegal? As a Doctor do they not know what insurance companies they participate in?

[Michele]

As I stated, the first thing you need to do is to call the provider.  There may have been a mistake in the processing of your claim that may have to be corrected.  Again, if you asked them if they accepted your insurance that is different then asking if they participate with your insurance.  Personally, I believe that if a person inquires if a provider accepts their insurance and that provider is out of network then they should advise the patient of that before they are seen, however not all providers offices do that.  BUT until you call to find out if it was a mistake the rest of that is mute.  You really need to call and speak to the provider's office before you can go any further.

[PMRNC]

Unfortunately the patient has the responsibility of making sure they see providers in their networks. If you look at your insurance policy it will state this. I do believe it is more ethical if a provider notifies you up-front to make sure, but again, the responsibility is with the patient. If this was an emergency room visit there is room for appeal if indeed the provider was out of network.  I would still call the provider to be certain the claim was processed correctly as out of network, and also I would still do an appeal and perhaps they can negotiate a par relationship for this visit, sometimes carriers will do this.