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rated:
A friend of mine at work got a surgery last month. After my insisting on making sure all staff and facility is in network, he was fine and all. He made sure everything is in network.

A month after receives a bill for 10K and shows to me. I told him this is impossible. He calls insurance company and they say some surgeon which is out of network showed up in the surgery room and thus he is billed.
Then he calls the hospital, hospital says the usual staff was not there, someone called sick the other was called to a different surgery so they had to call this person from outside.
So, how do you avoid this? Maybe we should tell the hospital admin not to allow non network people inside the surgery room? If there is no in network people to do the surgery then postpone the operation?

How do you avoid this?

EDIT: It is the surgical assistant that he was billed for. Insurance only pays in network part refuses to pay the difference between in network and out of network.

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rated:
Appeal the claim with the insurance company.
State that the Hospital was In-Network, and the scheduled Doctor was In-Network. Once you're under, you have no control over who shows up and does what during surgery.

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Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.

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Write with a sharpie on the body part "NO OUT OF NETWORK"

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Another great example of why the health care system isn't working right.

How many other businesses do the work without arranging payment up front? The surgeon / hospital knows the system, if they chose to do "network jobs" when they aren't in the network, then it seems logical that they must accept the network rate.

rated:
Rubl said:   Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.
 

  

No, you are quite incorrect there.  There is a whole lot of the story missing.  As stated, the OP sounds like an urban legend the OP is trying to pass off as the truth.  In a non-emergency, no surgeon with a license is going to touch you as they don't want problems that could arise. 

OP:  How about telling us the REST of the story?

 

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I'm guessing OPs friend was made aware that there was a replacement surgeon or at least introduced to the surgeon in question, but just not aware that the replacement was out of network.

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Separate billing by all parties involved is what makes this a train wreck, If you got billed for a procedure all-in by a network provider hospital, none of this would happen. It's evil.

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This is a big risk to the narrow network ACA plans being forced on the individual market to cut costs.  You can always get an unexpected out of network bill and you're on the hook for all of it unless you manage to plead with your insurance company to cover it anyway.  Plenty more real examples of this kind of stupidity here:

http://kiddynamitesworld.com/healthcare-will-screwed-stop-accept...

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Kaiser

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I'd think the insurance would still pay the surgeon, but at an out of network rate. Tell him to take it or leave it, and in fact, since he wasn't authorized by the patient to perform the procedure, he could be in trouble on many other levels.

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atikovi said:   I'd think the insurance would still pay the surgeon, but at an out of network rate. Tell him to take it or leave it, and in fact, since he wasn't authorized by the patient to perform the procedure, he could be in trouble on many other levels.
  No.  That's how PPO plans work.  insurance cos have mostly eliminated those from the individual market.  Employers also have cut back on allowing people to choose to pay for them in employer connected plans as well because they have determined that it's in the employee's best interest not to have the option of paying more for PPO (More accurately, they can pretend they kept premiums down and lower their employer contribution.).  HMO and EPO both only pay in network.  $0 to out of network, except in case of emergency, which a pre-scheduled surgery is not.

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halterk said:   Appeal the claim with the insurance company.
State that the Hospital was In-Network, and the scheduled Doctor was In-Network. Once you're under, you have no control over who shows up and does what during surgery.

  My friend already called the insurance company and they said "it ain't our problem buddy"

Hospital says "this is the way it has been"

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Rubl said:   Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.
  Maybe surgeon maybe not

Appearantly someone in the operation room. The bill did not say what his profession was

rated:
Mickie3 said:   
Rubl said:   Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.
  

No, you are quite incorrect there.  There is a whole lot of the story missing.  As stated, the OP sounds like an urban legend the OP is trying to pass off as the truth.  In a non-emergency, no surgeon with a license is going to touch you as they don't want problems that could arise. 

OP:  How about telling us the REST of the story?

 

  I am not hiding anything

I am just passing along the info I have been told

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Bend3r said:   
atikovi said:   I'd think the insurance would still pay the surgeon, but at an out of network rate. Tell him to take it or leave it, and in fact, since he wasn't authorized by the patient to perform the procedure, he could be in trouble on many other levels.
  No.  That's how PPO plans work.  insurance cos have mostly eliminated those from the individual market.  Employers also have cut back on allowing people to choose to pay for them in employer connected plans as well because they have determined that it's in the employee's best interest not to have the option of paying more for PPO (More accurately, they can pretend they kept premiums down and lower their employer contribution.).  HMO and EPO both only pay in network.  $0 to out of network, except in case of emergency, which a pre-scheduled surgery is not.

  Exactly

Insurance company said "your plan does not cover out of network"

rated:
The real question is

How do you avoid something like this?

Any suggestions? I mean he did everything I told him. There is nothing else one could have done?

Maybe inform the operation room or the hospital admin that you do not want non network people in the surgery ???

Is this possible?

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atikovi said:   I'd think the insurance would still pay the surgeon, but at an out of network rate. Tell him to take it or leave it, and in fact, since he wasn't authorized by the patient to perform the procedure, he could be in trouble on many other levels.
  Sure. But my out of network rate is zero.

A law saying that (all) providers have to accept insurance assignment as payment in full would solve this. At the expense of a lot of good providers not taking my insurance,

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I dunno, my wife went into have a physical this month, they did 2 labs.  Doctor was in network, we got the bills and it said labs were covered, in network too.  Then we got a letter saying that a different lab person had signed off on one of the tests and that one was now out of network, so we owe $180.  I had a physical this summer, the same doctor, everything was in network, but then they wanted to do a fast EKG, so a nurse did it (takes like 15 seconds to do the test after they get the electrodes are on) and voila, some doctor I've never heard (not the nurse) of was listed as performing the EKG and it was suddenly out of network, cost: $400. 

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I swear that you'd solve half the problems with health care costs if the law mandated transparency on costs. The use of "networks" masks the cost from the consumer who then has no idea how to compare both quality and price between various providers.

They make you sign the HIPAA waiver any time you see one of these guys... doesn't seem like much of a stretch to require a price list along with that.

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This is ridiculous...

You gotta have Masters in Health Care to navigate the system nowadays and even with that you have no power. There is nothing to protect the consumer.

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fleetwoodmac said:   
Rubl said:   Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.
  Maybe surgeon maybe not

Appearantly someone in the operation room. The bill did not say what his profession was

  
This sets off my troll-dar. Should be pretty easy to figure out who this bill is from.

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My wife was in the hospital few years ago. Some Dr. walked into her room, introduced himself, looked at the monitors connected to her, made couple of notes, and walked out.
Few months later we received a separate bill for about $700 from this doc because he wasn't a member of the hospital staff, and our insurance refused to cover his "services". I made a huge stink, threatened to complain to the Dept. of Health and the state AG for allowing unauthorized personnel in the room and overbilling and something else(my wife is a RN, she knows the correct terminology). Long story short, they said the bill was a mistake.

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Something similar happened when we hard our first child but it didnt turn out bad. Hospital and Doc were in network but Doc wasn't on-call when wife went into labor. No one from the practice was on but they had an arrangement with the house OB and he delivered baby. On the EOB from insurance it had my wife's doc. They must have paid that to the house OB. That is the way it should work if you are covering for someone, you should have to accept the same payment that insurance would provide.

rated:
Mickie3 said:   
Rubl said:   Some surgeon whom the patient never consented to do any surgery did the surgery? Some part of the story is missing.
  

No, you are quite incorrect there.  There is a whole lot of the story missing.  As stated, the OP sounds like an urban legend the OP is trying to pass off as the truth.  In a non-emergency, no surgeon with a license is going to touch you as they don't want problems that could arise. 

OP:  How about telling us the REST of the story?

 

  I'm pretty sure you give permission tto have anyone work on you whether they are in network or not.  This happened to me and to my wife.  In my case, I asked the facility and the insurance company if everyone involved (colonoscopy) was in-network and they told me they were and everything was covered.  When I got a bill from the out-of-network Anesthesiologist, I inquired and the facility told me then never had an in-network anesthesiologist and tough luck.  The insurance company said tough luck.  In this case, it had a good ending.  I protested to the doctor and his billing person said tough luck but they never billed me for the balance and didn't ding my credit score so I'm happy.  Try negotiating with the out-of-network doctor.  In my wife's case, they needed an assistant surgeon and the insurance company negotiated with the out-of-network surgeon and it took a year but they finally approved it as an emergency.

rated:
I hate the fact that if I am sitting in a doctor's office/hospital room, I have to be vigilant about who comes in to the room to ask me questions and look at the monitor because I could get a bill from them.

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vnuts21 said:   I hate the fact that if I am sitting in a doctor's office/hospital room, I have to be vigilant about who comes in to the room to ask me questions and look at the monitor because I could get a bill from them.
Billion dollar app idea. Make all the physicians and staff wear barcoded or RFID wristbands. Use the app to scan each person as they walk in the room and it tells you whether they are in- or out-of-network. Doesn't work as well under anesthesia.

rated:
TravelerMSY said:   Separate billing by all parties involved is what makes this a train wreck, If you got billed for a procedure all-in by a network provider hospital, none of this would happen. It's evil.
  
Agreed.  If surgeon X is going to perform a procedure on you, and says the surgery should take place at hospital Y, then you should pay surgeon X, period. It's the service provider's job to pay the subcontractors on whatever terms he/she negotiates with them, not yours.  

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So what happens in this case if the patient is on Medicaid?

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Yebala said:   My wife was in the hospital few years ago. Some Dr. walked into her room, introduced himself, looked at the monitors connected to her, made couple of notes, and walked out.
Few months later we received a separate bill for about $700 from this doc because he wasn't a member of the hospital staff, and our insurance refused to cover his "services". I made a huge stink, threatened to complain to the Dept. of Health and the state AG for allowing unauthorized personnel in the room and overbilling and something else(my wife is a RN, she knows the correct terminology). Long story short, they said the bill was a mistake.

  I learned the phrase "drive-by-doctoring" after my dad pass away from cancer.'

To all you MDs out there, you have a responsibility to your profession to clean up this BS.

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cestmoi123 said:   
TravelerMSY said:   Separate billing by all parties involved is what makes this a train wreck, If you got billed for a procedure all-in by a network provider hospital, none of this would happen. It's evil.
  
Agreed.  If surgeon X is going to perform a procedure on you, and says the surgery should take place at hospital Y, then you should pay surgeon X, period. It's the service provider's job to pay the subcontractors on whatever terms he/she negotiates with them, not yours.  

  Sadly, this is not what happens.  Doctors are considered independent contractors who bill you directly.  That's good for them because of the way the American tax laws work.  They visit their records in a room or basement of their home every morning.  That makes that space a tax deductible business expense.  Then they get in their car and drive to the hospital.  This is no longer commuting but a trip between business locations and, you guessed it, tax deductible. As an independent business, they set up a deductible college scholarship for their children.  There are more of these tax deductions so they get rich off of our money.  The hospital can truthfully say that they have little control.  This HAS to be stopped but because doctors pay tons of $$$ to lobbyists, this probably will not happen for a very long time.

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TheBigCheese said:   
cestmoi123 said:   
TravelerMSY said:   Separate billing by all parties involved is what makes this a train wreck, If you got billed for a procedure all-in by a network provider hospital, none of this would happen. It's evil.
  
Agreed.  If surgeon X is going to perform a procedure on you, and says the surgery should take place at hospital Y, then you should pay surgeon X, period. It's the service provider's job to pay the subcontractors on whatever terms he/she negotiates with them, not yours.  

  Sadly, this is not what happens.  Doctors are considered independent contractors who bill you directly.  That's good for them because of the way the American tax laws work.  They visit their records in a room or basement of their home every morning.  That makes that space a tax deductible business expense.  Then they get in their car and drive to the hospital.  This is no longer commuting but a trip between business locations and, you guessed it, tax deductible. As an independent business, they set up a deductible college scholarship for their children.  There are more of these tax deductions so they get rich off of our money.  The hospital can truthfully say that they have little control.  This HAS to be stopped but because doctors pay tons of $$$ to lobbyists, this probably will not happen for a very long time.

  Maybe it is like this in some areas, but I know many doctors, and none of them do this.

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TheBigCheese said:   
cestmoi123 said:   
TravelerMSY said:   Separate billing by all parties involved is what makes this a train wreck, If you got billed for a procedure all-in by a network provider hospital, none of this would happen. It's evil.
  
Agreed.  If surgeon X is going to perform a procedure on you, and says the surgery should take place at hospital Y, then you should pay surgeon X, period. It's the service provider's job to pay the subcontractors on whatever terms he/she negotiates with them, not yours.  

  Sadly, this is not what happens.  Doctors are considered independent contractors who bill you directly.  That's good for them because of the way the American tax laws work.  They visit their records in a room or basement of their home every morning.  That makes that space a tax deductible business expense.  Then they get in their car and drive to the hospital.  This is no longer commuting but a trip between business locations and, you guessed it, tax deductible. As an independent business, they set up a deductible college scholarship for their children.  There are more of these tax deductions so they get rich off of our money.  The hospital can truthfully say that they have little control.  This HAS to be stopped but because doctors pay tons of $$$ to lobbyists, this probably will not happen for a very long time.

Send Trump your ideas. Posting even the obvious here might not be enough.

rated:
Maybe you can contact your Assembly Member, and your Senator to help stop what happened here. I did!

Consumers Union     
Dear XXXX
We all work hard to afford health care in New Jersey. And when we get sick, we expect our insurance to cover our medical expenses. But for too many New Jerseyans, that’s not what happens.

We recently heard from Yvonne, whose husband had heart attack symptoms and was rushed to the hospital. The facility was “in network,” so she thought her health insurance would pay for the cost of his emergency room visit. But for a one-night stay in the hospital, Yvonne and her husband were billed thousands of dollars because some of the doctors and treatment tests were considered “out of network” by the insurance company. Yvonne did everything in her power to avoid outrageous medical bills, but she wasn't told which doctors or tests wouldn't be covered by her insurance, and she was still hit with the bill.

Yvonne is far from alone.

Robert, who despite checking with the hospital and all his doctors in advance, received a $3000 surprise bill from an anesthesiologist he never even met. Michael and his wife were billed $1,520 for a genetic test that was sent to an out-of-network lab out of state. We’ve heard these stories from thousands of Americans. Now, there’s a way to fight back.
A bill making its way through the New Jersey’s Assembly and Senate would ensure that New Jerseyans know exactly how much they’ll have to pay before receiving medical care. The bill requires that patients provide up-front permission before they’re charged for any additional costs. It also protects patients from these costly surprise bills in an emergency situation if they are unable to make a decision in advance.

Tell your Assembly member and Senator:
New Jerseyans deserve protections from  costly surprise medical bills now! We won earlier fights and secured these protections in New York, California and Florida -- and now it’s New Jersey’s turn.

The healthcare industry is lobbying heavily to stop this legislation and you can bet your lawmakers are hearing from them. Working together, we can make sure they are also hearing our side loudly and clearly from constituents.
It’s not too much to ask that medical costs be transparent and fair, that insurance be there when you need it the most.
The good news is that this bill has widespread popular support: we can get it passed it if everyone speaks out now. If New York, California, and Florida can guarantee these protections for their residents, then so can New Jersey.
Stand with Consumers Union and ask lawmakers to pass this bill. We can’t afford to wait while patients are saddled with devastating and unfair bills.
In some of the hardest moments of life, New Jerseyans should know that they’re protected from these horrific financial challenges.
After you send your message, please forward this email to your friends and family to keep up the pressure on lawmakers. And thank you for sending them this important message today. It’s your activism that will make progress for consumers possible.

Kimberly Fountain, Consumers Union
Policy and Action from Consumer Reports


 

rated:
Please tell me you patented this idea because it is pure genius..(Only half kidding)

rated:
fleetwoodmac said:   A friend of mine at work got a surgery last month... He calls insurance company and they say some surgeon which is out of network showed up in the surgery room and thus he is billed... So, how do you avoid this?
Place (temporary) tattoos all over your body (forehead, chest, stomach, upper back, lower back, front and back of legs, etc.) listing your insurance provider, policy #, policy type (HMO, PPO, etc.) and a message saying "If you ARE NOT an IN-NETWORK provider for the insurance policy listed here, you are NOT AUTHORIZED to treat me."

Note: If your hair normally covers your forehead, ensure that it's pulled back so that the forehead is clearly visible (or just cut your hair short).

 /sarcasm (sort of)

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TheBigCheese said:   In my case, I asked the facility and the insurance company if everyone involved (colonoscopy) was in-network.. In this case, it had a good ending.
A colonoscopy with a good ending huh?
  

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TheDiggler said:   
TheBigCheese said:   In my case, I asked the facility and the insurance company if everyone involved (colonoscopy) was in-network.. In this case, it had a good ending.
A colonoscopy with a good ending huh?
  

  The end is the just the beginning of a colonoscopy.

Skipping 118 Messages...
rated:
If you've done everything right, at some point you have to tell them to go pound sand and threaten to sue them for damages if they report the debt to the credit agencies.

We had this situation not too long ago--in network hospital, out of network doctor who supposedly visited but we had no recollection of seeing that person. Insurance wouldn't pay some ridiculous fee, we said we weren't going to pay it because we did tell the hospital up front no out of network folks, the doctor's group threatened to report us to collections and the credit agencies, and we told them to go ahead and as soon as it showed up we'd be filing a lawsuit for damages. Surprise, surprise, it went away.

Some of this stuff is just extortion. You have to fight back.

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