Complaint 5 of 5 in “In Network / Out of Network Issues”

UPDATED: Aug 18, 2020

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  • Insurance Carrier: Pearce Administration
  • State: FL

Consumer Complaint:

Halfway through my pregnancy my OB/GYN informed me that they would no longer be accepting my insurance. I went to my insurance’s website to find the list of Dr.’s and hospitals that were in-network. My new Dr. contacted the insurance and to find out the contracted rate and I signed and paid an OB Budget agreement. I paid my in-network 20% in full on 9/22/08. Now the insurance company is saying the Dr. is out of network and is only paying 60%. I have this same issue with the hospital where I delivered. I did not prepay with them, but no one at the the hospital ever said that the hospital was out of network. The manager at the insurance company says she is trying to get this resolved, but now the Dr.’s bill has gone to collections. The hospital is giving me 30 more days to try to resolve this.

Insurance Expert Answer:

If the insurance company's website said the physician was in-network, and you relied on that to your detriment, the company should be held to it. As you signed an agreement with the doctor that presumed he would accept the 20% from you and the rest from your carrier, he should be held to that as he and the carrier are in the best position to know whether is was or was not in-network.

However, if you used a hospital that was not in-network and the website did not say it was in-network, the problem is not with the insurance company but is a problem between you and your hospital and not your insurance company. It's up to you to ask (as you did with your doctor) not for someone else to volunteer, although it despicable that they did not tell you.

Some thoughts --

1. Go to your employer's benefits people and ask them to go to bat for you. At a large employer the benefits people have far more clout than you do.

2. Consider speaking to a lawyer. A letter from the lawyer to the collections people will shut them up and force them either to wait or to sue. The lawyer may also have some idea as to how to handle the matter, and the few hundred dollars you'd likely have to spend for a consultation can save many more dollars and much anguish.

3. If worse comes to worst, you should find out what the hospital's negotiated rates are with other providers and what its medicare rates are, and not agree to pay any more than those. The hospitals negotiate low rates with insurance companies and charge the poor uninsured person walking in off the street the \"rack rate\" with is generally many times higher than the negotiated or Medicare rate. A strong argument can be made that the average negotiated rate or the Medicare rate rather than the rack rate is the prevailing rate at the hospital.

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