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Rosie4
LIF Adolescent
Member since 2/12 643 total posts
Name:
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Be aware of doing expensive procedures out of network
I just recently found out that when going out of network with health insurance, the amount you get back is set at Medicare rates, which is extremely low. I just recently wanted to have surgery done by an out of network doctor, and I would only get $3,000 back from $23,000. It used to be reasonable and customary rate, which still was low, but when it was determined we would get screwed by the lower rates, they did an overhaul of how it works and now it is worse. I did a search of this online and there is a lot of info on it and I verified this with my insurance, BC/BS. Just make sure you find out exactly how much you would get back before going out of network. Now I have no choice and have to use an in network doctor and my surgery is postponed, as I have to start my dr consults all over again. I finally decided on the dr I want to use for my surgery and now I can't use him, as it will cost me $20,000 even after my insurance reimburses me. 
Message edited 7/1/2013 9:42:59 AM.
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Posted 7/1/13 9:33 AM  |
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Lillykat
going along for the ride...
Member since 5/05 16253 total posts
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Re: Be aware of doing expensive procedures out of network
Not always. Did you try to negotiate with the dr? My DD had surgery recently with a dr out of network bc he is the best. We asked him directly not the office staff. He was happy to negotiate and accept what other companies pay him. He said that they do it all the time. Then the hospital etc were all in network. I know many other people who had done the same. Many drs do not take insurance or are willing to negotiate their rates.
Do you have an out of pocket max? Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest.
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| Posted 7/1/13 11:04 PM |
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sunnyflies
LIF Adult
Member since 9/09 1757 total posts
Name:
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Be aware of doing expensive procedures out of network
"Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest."
I wish that was true, but it isn't. They only pay what they consider to be fair out of pocket which is quite different from the actual out of pocket costs. I just went through a year of cancer treatments and learned that the hard way. I hit the deductible immediately and hadn't reached the out of pocket max 12 months later because of how they figure their costs. I had to pay the difference on many bills " out of pocket" as the insurance wouldn't cover it, nor would it credit me for having to pay it.
Like the OP, I had to make doctor choices based on in and out of network. While some of the surgery by an out of network doctor - tops in her field - would have been partially covered, the way they break an operation down into codes meant that the the first coded procedure would have been paid at 80%, but the other codes would have only been covered at 40%.
Message edited 7/2/2013 1:08:53 AM.
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| Posted 7/2/13 1:07 AM |
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NervousNell
Just another chapter in life..
Member since 11/09 54921 total posts
Name:
..being a mommy and being a wife!
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Re: Be aware of doing expensive procedures out of network
Posted by Lillykat
Not always. Did you try to negotiate with the dr? My DD had surgery recently with a dr out of network bc he is the best. We asked him directly not the office staff. He was happy to negotiate and accept what other companies pay him. He said that they do it all the time. Then the hospital etc were all in network. I know many other people who had done the same. Many drs do not take insurance or are willing to negotiate their rates.
Do you have an out of pocket max? Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest.
I agree with this. I went to the ER (at in in network hosptial mind you) and wound up being admitted and needing surgery to remove my gallbladder. The surgeon on call did the surgery. He was the only surgeon there at the time.
We ended up getting a bill because he was not in network- the hosptial was, he personally was not.
I ended up with a bill for $11,000 
I called the office and they ended up accepting whatever my insurance paid for out of network.
We never heard another word about it
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| Posted 7/2/13 7:28 AM |
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Diane
Hope is Contagious....catch it
Member since 5/05 30683 total posts
Name:
D
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Re: Be aware of doing expensive procedures out of network
Posted by NervousNell
Posted by Lillykat
Not always. Did you try to negotiate with the dr? My DD had surgery recently with a dr out of network bc he is the best. We asked him directly not the office staff. He was happy to negotiate and accept what other companies pay him. He said that they do it all the time. Then the hospital etc were all in network. I know many other people who had done the same. Many drs do not take insurance or are willing to negotiate their rates.
Do you have an out of pocket max? Most plans with deductibles or copayments have one. Once you reach the amount they pay the rest.
I agree with this. I went to the ER (at in in network hosptial mind you) and wound up being admitted and needing surgery to remove my gallbladder. The surgeon on call did the surgery. He was the only surgeon there at the time.
We ended up getting a bill because he was not in network- the hosptial was, he personally was not.
I ended up with a bill for $11,000
I called the office and they ended up accepting whatever my insurance paid for out of network.
We never heard another word about it
The same exact thing happened to me.
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| Posted 7/3/13 12:41 PM |
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Lillykat
going along for the ride...
Member since 5/05 16253 total posts
Name:
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Re: Be aware of doing expensive procedures out of network
Well I just had a 10k deductible plan and hit both the deductible in network and out. Paid the coinsurance until out of network until I hit out of pocket max. They paid 100% after. I frequently go OON bc I am very picky about drs and use some who don't take insurance. I have also done that in the past with other plans and companies. My drs have always accepted what insurance pays them. One time I had an issue. I appealed and it was resolved.
Have you tried appealing?
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| Posted 7/4/13 7:41 AM |
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Rosie4
LIF Adolescent
Member since 2/12 643 total posts
Name:
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Re: Be aware of doing expensive procedures out of network
Posted by Lillykat
Well I just had a 10k deductible plan and hit both the deductible in network and out. Paid the coinsurance until out of network until I hit out of pocket max. They paid 100% after. I frequently go OON bc I am very picky about drs and use some who don't take insurance. I have also done that in the past with other plans and companies. My drs have always accepted what insurance pays them. One time I had an issue. I appealed and it was resolved.
Have you tried appealing?
Did you get 100% of the full price charged or the reasonble and customary after you paid your out of network coinsurance? One time I met the coinsurance for out of network and got the full 100% back of the full price charged, but when I called the insurance about this, I will meet the full amount of coinsurance with the surgery of course, but they said 100% of the reasonable and customary, which they use what Medicare pays. Are you saying to appeal to the insurance? I did that once and won, but I believe if there is another dr in the area that does what you need they won't give it to you and there are other drs, but not ones I want to use for this surgery. As you said, I am very picky about drs and I never had a surgery this invoving. I just had a consult with a dr that doesn't take my insurance and they are taking what the insurance gives for the consult, which is more than if I came in and paid cash as a noninsured patient. Also had another dr out of network take what my insurance gave, minus the deductible and coinsurance, but I think this dr wants the money up front.
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| Posted 7/4/13 9:02 AM |
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sunnyflies
LIF Adult
Member since 9/09 1757 total posts
Name:
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Be aware of doing expensive procedures out of network
My plan only pays OON doctors what is reasonable and customary which is way less than they charge - and top doctors in Manhattan don't negotiate. They figure if you want them, you pay for them, otherwise go to someone else. Many do not take any insurance at all.
Just be clear about what is and is not covered.
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| Posted 7/4/13 7:19 PM |
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itsbabytime
LIF Adult
Member since 11/05 9644 total posts
Name:
Me
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Re: Be aware of doing expensive procedures out of network
Posted by sunnyflies
My plan only pays OON doctors what is reasonable and customary which is way less than they charge - and top doctors in Manhattan don't negotiate. They figure if you want them, you pay for them, otherwise go to someone else. Many do not take any insurance at all.
Just be clear about what is and is not covered.
Yes - this is true. Even when you meet the OON maximum and assuming ins. covers everything it might not be the entire bill and if your DR. is OON they do not have a contract with the insurance company so they are not obligated to accept what the insurance company deems reasonable and customary so you would still (even after meeting the max) be responsible for everything over the reasonable and customary which can add up to ALOT! Also, even if you have a maximum out of pocket as per the insurance - if the doctor doesn't have a contract with the insurance carrier they are not bound by this. And, I agree, not all Doctors negotiate. And, even when they do it might still leave you with a $$$ bill!!!
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| Posted 7/5/13 12:14 AM |
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Rosie4
LIF Adolescent
Member since 2/12 643 total posts
Name:
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Re: Be aware of doing expensive procedures out of network
Thanks for all the responses.
I am wondering, if a dr that is out of network and is going to cost a lot out of pocket, considers if you spent out of pocket a lot of money at their office in the past.
Message edited 7/5/2013 7:58:10 AM.
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| Posted 7/5/13 7:57 AM |
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butterfly20
Party of 5 - 2015
Member since 4/06 7390 total posts
Name:
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Be aware of doing expensive procedures out of network
Wih our medical plans I have noticed oon providers have double the deductible amount... I avoid them completely now.
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| Posted 7/5/13 4:28 PM |
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Lillykat
going along for the ride...
Member since 5/05 16253 total posts
Name:
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Re: Be aware of doing expensive procedures out of network
Posted by sunnyflies
My plan only pays OON doctors what is reasonable and customary which is way less than they charge - and top doctors in Manhattan don't negotiate. They figure if you want them, you pay for them, otherwise go to someone else. Many do not take any insurance at all.
Just be clear about what is and is not covered.
It really depends on the dr. The one who did my DD's surgery was willing to take reasonable customary (medicare rate). He is top oc his field in best drs in NY andpart of NYU and cornell. My insurance paid actually the 70% (coinsurance) of what he actually billed ( but he might have billed the amount he knew they would pay).
Some top dr will negotiate some won't some take customary some don't. Actually mine went by the amount billed by thr doctor this time I ask the dr directly not the office staff. And yes I am talking about top NY drs at cornell and columbia some who take no insurance some who do just not mine. It never hurts to ask. For this past time the hospital and anast were in network only the dr charge was out. He said he does that all thr time.
I also used to go to a dr for my mammos who was oon. They always paid her fee in full once I reached the oop. She took no insurance.
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| Posted 7/8/13 10:13 PM |
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