UrbanBaby

06.02.08, 09:16 AM General Topics
14 replies

insurance and ER question. if the doctor is charging more than what hte insurance company is reimbursing him, is the patient responsible for the difference? (repost. trying to see if anyone knows definitively). (and btw, the doctor is a plastic surgeon. i don't know if that makes a difference.) TIA. [ Reply | Watch | Flag ]
General Topics 06.02.08, 09:16 AM Flag

Dear UrbanBaby community,

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Is the hospital in-network? Were you given a choice in doctors (plastic surgeon vs. regular ER doctor)? [ Reply | More

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General Topics 06.02.08, 09:17 AM Flag

yes and yes. they asked me if i wanted a plastic surgeon and i asked what the downside would be. they said some insurance companies won't cover it and asked me which insurance co i use and then i was told to use the plastic surgeon. fwiw, the doctor is saying they are reimbursing him at the "participating provider rate" and he wants more b/c he's not a participating provider. [ Reply | More

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General Topics 06.02.08, 09:21 AM Flag

Tough one. Technically, since you agreed to use him after being offered someone in-network, he can charge you. But I'm guessing you can deny, deny, deny - see what happens. [ Reply | More

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General Topics 06.02.08, 09:22 AM Flag

thanks. why doesn't he have an obligation to tell me he's not covered by my insurance? [ Reply | More

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General Topics 06.02.08, 09:26 AM Flag

When you are in the hospital, it is the hospital's responsibility according to your insurance. But plastic surgery is always tricky because it is rarely necessary, it is just wanted for better aesthetic results. [ Reply | More

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General Topics 06.02.08, 09:27 AM Flag

it's so upsetting. i was sitting there for hours. you'd think someone could've taken three minutes just to notify me that it may not be covered by my insurance. [ Reply | More

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General Topics 06.02.08, 09:30 AM Flag

Call the hospital and complain. [ Reply | More

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General Topics 06.02.08, 09:30 AM Flag

^^^Also, call your insurance. The issue will be the plastic surgery wasn't necessary, so their contract with the hospital was not broken. This is the hospital's fault (and it happens all the time). [ Reply | More

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General Topics 06.02.08, 09:31 AM Flag

the doctors in the hospital (when I worked in hosp billing this was often a problem with the anesthesiologists) don't have to be contracted with your insurance, even if the hospital is. If you look at it from their perspective, they're giving you a service, and you have to pay them, and your insurance is your business. It is definitely the responsibility of the patient to know his or her own coverage, but it's not like you're going to know which doctors are contracted with your insurance when you're lying on a gurney, or when an anesthesiologist comes in to talk to you just prior to surgery! It's a problem, definitely [ Reply | More

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General Topics 06.02.08, 09:30 AM Flag

OR: Rules are different now with HMOs. For something like anesthesiology, where you are not given a choice in doctors, the insurance contract with the hospital and all their contracted doctors says you are not obligated to pay the difference (most HMOs will pay a little more, and the anesthesiologists now are given salaries through hospitals in addition to the insurance money). [ Reply | More

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General Topics 06.02.08, 09:33 AM Flag

OP: thank you, all above posters. this is ridiculously complicated. i'm afraid that as the patient, i've drawn the short straw in this issue. [ Reply | More

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General Topics 06.02.08, 09:36 AM Flag

Since he is not a participating provider, he can charge more. [ Reply | More

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General Topics 06.02.08, 09:26 AM Flag

but why doesn't he have an obligation to let me know? [ Reply | More

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General Topics 06.02.08, 09:29 AM Flag

responded above [ Reply | More

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General Topics 06.02.08, 09:30 AM Flag