Surprise Out of Network Bill

I recently had surgery. It was planned, and I did due diligence to ensure that the surgeon, the surgery center and the anesthesiologist were in network as in network costs are much more affordable to me than out of network costs with my PPO insurance plan. They were all in network with reasonable costs. This weekend I received a bill for a surgical assistant PA who happens to be out of network. I had no idea there would be any surgical assistant. In fact, this bill is larger than what the surgeon submitted to the insurance company. It is exorbitant even after my out of network adjustment was made. I contacted my insurance company this morning, and they tried calling the surgical assistant practice. The practice said the bill must be paid in full. My insurance company said I should put in an appeal to see if something can be done. I did that today, but I think it’s futile.

If this happened to you, did you have any successful resolution? I do not want to pay this bill so I assume it will go into collections and just keep increasing. I don’t want to set up a payment plan either as I think this is just blatantly unfair. I am considering hiring a lawyer, but I don’t even know where to start or additional costs I might incur.

Any insight will be appreciated. Thanks.

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This has happened to me also. I went directly to my original surgeon, ( since he requested the assistant ) and explained the assistant was out of network and was charging me more than he was! My surgeon worked it out with the assistant to have the cost reduced from $7K to $500 which I happily paid. I did this in person, with the bill in hand, not on the phone. I hope you get it resolved.

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I was scared of this the last couple of times I had surgeries as I had heard of it happening to people. Somewhere in the process of arranging the first surgery I said I wanted only doctors and medical personal that were in my network when I set up the surgeries with the hospital involved. That smaller hospital said they never used medical personal that didn’t take the insurance payment the patient had. The second hospital said everything would be prior authorized with my insurance. That second surgery involved pulling in a specialist from out of state, but it was sought by the orthopedic department of that hospital and was all preapproved. I was using a narrowed “network” insurance at that time and the hospital, ortho department etc were all not in my narrowed network, but would have been in the regular network. But my medical group/network referred me to them in the first place. So everything was preapproved.

It’s worrisome that this can happen to people and how do you know who all will end up being involved in the surgery? My only suggestion is like @Gail12 has said contact the doctor and find out if he is the one that arranged the assistant and maybe you can get them to to arrange something as they knew what your insurance was and they used someone that wasn’t in it. The other possibility is if it was the hospital that arranged the assistant contact them with the same information that why did they assign someone that wasn’t in your network.

Ouch…

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Thank you. I called the surgeon yesterday. Hopefully, they can help.

The cost of this medical bill is outrageous, but I agree in that what is so worrisome is that this even happened. This was planned surgery so I diligently checked about in network providers with my insurance company and with the actual provider. I just had no idea. What makes this even worse is that I have out of network coverage, and this bill still is so high. Thank you.

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As a person in Canada, I find this whole discussion absolutely baffling and amazing.
Possibly many people in the US get better results (possibly) and shorter wait times. But potential bankruptcy and debts hanging over your heads for something you have no control over or choice about just seems like straight from Victorian times. “Straight to the poor-house!”

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I would talk to my state insurance board also. This is outrageous. Best of luck in resolving this problem. Nancy50

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I use a different kind of insurance, Kaiser Permanente, and I don’t have to deal with this kind of stuff it’s more expensive for premiums, but the costs are very up front.
This kind of issue is exactly where it works our very well.

A lot of people have a hard time with the system, sometimes getting approved for things etc, but I’ve been on it 25 years and it’s been good for me.

I had a parotidectomy, it involved facial nerves, so I needed an ENT surgeon and a neurology surgeon. Plus all the added staff, I had no idea about.
3 days in the hospital and I got a bill of $250.

There is no perfect system. Nothing works 100% of the time.

You are experiencing the big problem with The American medical system, there is just very little consumer protection.

I hope you can get this sorted out.
It seems odd to me that an out of network assistant could be assigned to you without your knowledge.

Maybe you can get the insurance company to reconsider.

I agree. It’s ludicrous. And again, I have fairly decent insurance with lower monthly premiums, great prescription benefits, no co-pays and out of network coverage, and something like this still happens. I shudder to think how people do it with no insurance or inadequate plans especially in dealing with a chronic disease.

Well there has been some hopeful news in talking to surgeon this morning. I was told to put in the appeal and wait for outcome. If it’s unacceptable, I should follow up again with surgeon to take care of it. I have no problem in paying a fair share, but it seems to me that this occurs more often than not. Providers submit a huge bill to insurance if not in network, insurance company pays out, provider then goes after patient for whole amount. Patient then fights or pays. If patient fights, provider settles for the smaller pay out or continues to try to get more. If patient pays, it’s a win win situation for provider. Hmmm. Seems crazy. My surgeon was fantastic, but I still think I should have been told about this out of network provider and this scam prior to surgery. We’ll see what transpires, but thank you all for your input.

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In another life, I would install and service various commercial electronic systems. When it was a small installation we would bill by piece and labor. Large installations were almost alway bid and were “turn key.” This meant the charge was all of a piece including labor and parts including and subcontractors.

It aggravates me no end how major surgery in doled out to so many different entities bill every little thing separately. I really think there should be one charge to the insurance company.

This came up years ago with my Dad. 2 years after a medical procedure he got a bill from some doctor 100 miles away. No explanation, just, we want our money. He came close to having a stroke over it. My wife took care of it.

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They bring in employees from Out of Network (into your network) and then charge out of network prices. Let me see if I can find more info…

Thank you. This whole scam, or whatever it should be called, has been eye opening for me.

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I had that happen a few years back…I contacted my insurance company and explained the situation. They said that since I wasn’t informed and couldn’t give consent, I was not responsible for the bill and the insurance company would take care of it.

Hopefully that will work for you.

I had this happen several years ago, after a trip to emergency room, and treated for kidney stone. Got a huge billing months later, but was able to get it reduced after contacting the hospital billing dept. They explained it was mistake on billers side, as they were supposed to have hospital tell them allowed amount per agreement they have.

Let’s get this straight. ERs and other hospital services relish the opportunity to bring in out of network medical personnel because their billing rates are not limited by your in-network established payments guidelines for medical services. I used to worry about out of network providers coming in to provide me care, but thankfully, I am now on Medicare, and almost everyone takes Medicare, and payment guidelines are negotiated by CMMS.

There have been congressional attempts to add clauses to bills to forbid out of network providers from charging outrageous amounts. But I do not believe that Congress has been too dysfunctional and too bought off by lobbyists to work together to put this in a bill.

Some states such as Colorado have put together their own laws such as the Consumer Protection Standards Act to limit charges in these situations. But yes, this is an ongoing problem. Solution: Get old quick and get on Medicare…LOL

Look for legislation related to ‘Surprise billing’ - that’s what they term it.

Thank you. I saw this over weekend when I was searching on any recourse when I saw the bill. In my case, this doesn’t start until January 2022. Had I known, I probably would have put off the surgery until 2022.

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Darn it. I feel for ya’. There’s some great books on the topic of goofy medical system operations/billing if your full of rage and in the mood. One is “An American Sickness,” and another is “The Price we Pay.” Elisabeth Rosenthal Explains How U.S. Health Care Became Big Business : Shots - Health News : NPR

Some states have regulations concerning such “surprise billing.” In New York state it is through the Department of Financial Services.