Can I win this? (insurance)

[nicolewi]

I'm super annoyed. DS had to have baby teeth removed and it's already cost us a lot of money. I'd say about $1,000 in so far on getting these stupid teeth out b/c they wouldn't come out on their own. 

Today I spent about 2 hours (not even kidding; it was horrible; I was placed on forever hold on one call and finally hung up after over an hour on speakerphone listening to hold music while I did other things) on phone calls and online chat with the oral surgeon and insurance to find out why I had another $400 bill when I thought everything was paid. Long story short, it turns out that the provider I chose is out of network. 

Before scheduling DS, I looked on the insurance company website for oral surgeons near me, choose one in network mostly based on location close to our house, and went with him. If I look up the provider today, he STILL says "in network," at the same address at which we saw him.

According to the oral surgeon's office, his practice was bought by another group last October and the NEW group is no longer covered by our insurance so he is no longer in network. 

I want to dispute this with the insurance since the info on their own website is incorrect and that's why apparently I have another $400 bill. 

Do you think I can win this or am I out of luck?

[mofongo]

Did you and the oral surgeons staff discuss it, there should be a conversation about pricing and insurance prior to services rendered. I feel like you’re probably out of luck, I run into this some at work.

[heygrey]

I would definitely try to fight it, but I wouldn't expect to win.

[bee20]

With threads like this I don't understand why we don't riot over the healthcare situation.

Yes, you can fight it. Make sure you have a screenshot of the website in case it changes while you're doing all of this.

Go ahead and start with the insurance company, but another avenue is whoever actually buys your health insurance. When I've worked at big companies there is a specific department in HR that just hassles the insurance company on behalf of employees for this kind of fuckery (I forget if their title was "benefits administrator" or "benefits liaison", but something like that). At my smaller company we have an HR person who is the benefits coordinator, he works with a benefits company that sells to us. Either way, you talk to that HR person and show them the screenshot and the bills. You tell them the insurance they are buying for their employees isn't doing what they said they would. HR forwards this to the insurance agent with a "wtf?" type form letter. The insurance company has a whole different department for dealing with their actual customers, who sadly isn't you or me.

I've had to do this twice, once for the insurance company denying me additional physical therapy sessions when I had an authorization letter for said sessions. Another time it was on whether care for a member of my family was truly emergency services, we had called the consulting nurse line and they advised we go to an ER. At the ER they did imaging and lab tests that showed the issue was stable and we could travel home for further care. In both cases once the actual customer called it was resolved without further effort from me. At big company the HR Benefits administrator person kept me on CC while she sorted it out, and at my smaller company I just got an email that the bills would be resent with it characterized as authorized emergency. In the first case I'd already spent hours and hours on the phone, the second time I knew better and only spent a few hours with the insurance company before elevating.

Sorry you're having to go through this.

[expectantsteelerfan]

The first thing I ask when calling any new provider is 'do you accept H insurance?' because our insurance is very clear that who is 'in-network' can change and their website isn't always up to date.

If you discussed insurance/cost with the provider before service and they said it would be covered, then I would absolutely fight it. If you didn't happen to do that, I would still be furious, but I don't think I would put the effort into fighting it because my experience dealing with insurance is that it's much like your experience of waiting forever on hold, getting disconnected, getting passed around, and I'd be even more mad to do that and then be told, 'sorry, the website is out of date, you should have checked before starting service.'

[Bad Dingo]

"Starting in 2022, the No Surprises Act requires all private health plans, including QHPs, to maintain accurate provider directories and requires providers to regularly update plans about any changes in their information. Plans must verify and update directories at least every 90 days and, on an ongoing basis, post any changes within 2 business days. Plans are also required to apply in-network cost sharing for covered services provided by facilities or providers mistakenly listed as in-network."

I'd send them this language and demand that you be charged the in-network amount. You could also reach out to your state Healthcare Advocate for advice.

[Bad Dingo]

Here is the pertinent section for the law: 

www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf

‘‘SEC. 2799B–9. PROVIDER REQUIREMENTS TO PROTECT PATIENTS AND IMPROVE THE ACCURACY OF PROVIDER DIRECTORY INFORMATION. ‘‘(a) PROVIDER BUSINESS PROCESSES.—Beginning not later than January 1, 2022, each health care provider and each health care facility shall have in place business processes to ensure the timely provision of provider directory information to a group health plan or a health insurance issuer offering group or individual health insurance coverage to support compliance by such plans or issuers with section 2799A–5(a)(1), section 720(a)(1) of the Employee Retirement Income Security Act of 1974, or section 9820(a)(1) of the Internal Revenue Code of 1986, as applicable. Such providers shall submit provider directory information to a plan or issuers, at a minimum— ‘‘(1) when the provider or facility begins a network agreement with a plan or with an issuer with respect to certain coverage; ‘‘(2) when the provider or facility terminates a network agreement with a plan or with an issuer with respect to certain coverage; dkrause on LAP5T8D0R2PROD with PUBLAWS ‘‘(3) when there are material changes to the content of provider directory information of the provider or facility described in section 2799A–5(a)(1), section 720(a)(1) of the Employee Retirement Income Security Act of 1974, or section 9820(a)(1) of the Internal Revenue Code of 1986, as applicable; and 26 USC 9811 prec. 42 USC 300gg–139. Effective date. VerDate Sep 11 2014 15:11 Oct 26, 2021 Jkt 019139 PO 00260 Frm 00641 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL260B.116 PUBL260B134 STAT. 2888 Reimbursement. Determination. PUBLIC LAW 116–260—DEC. 27, 2020 ‘‘(4) at any other time (including upon the request of such issuer or plan) determined appropriate by the provider, facility, or the Secretary. ‘‘(b) REFUNDS TO ENROLLEES.—If a health care provider submits a bill to an enrollee based on cost-sharing for treatment or services provided by the health care provider that is in excess of the normal cost-sharing applied for such treatment or services provided in- network, as prohibited under section 2799A–5(b), section 720(b) of the Employee Retirement Income Security Act of 1974, or section 9820(b) of the Internal Revenue Code of 1986, as applicable, and the enrollee pays such bill, the provider shall reimburse the enrollee for the full amount paid by the enrollee in excess of the in-network cost-sharing amount for the treatment or services involved, plus interest, at an interest rate determined by the Secretary. ‘‘(c) LIMITATION.—Nothing in this section shall prohibit a provider from requiring in the terms of a contract, or contract termination, with a group health plan or health insurance issuer— ‘‘(1) that the plan or issuer remove, at the time of termination of such contract, the provider from a directory of the plan or issuer described in section 2799A–5(a), section 720(a) of the Employee Retirement Income Security Act of 1974, or section 9820(a) of the Internal Revenue Code of 1986, as applicable; or ‘‘(2) that the plan or issuer bear financial responsibility, including under section 2799A–5(b), section 720(b) of the Employee Retirement Income Security Act of 1974, or section 9820(b) of the Internal Revenue Code of 1986, as applicable, for providing inaccurate network status information to an enrollee. ‘‘(d) DEFINITION.—For purposes of this section, the term ‘provider directory information’ includes the names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers, and the names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved. ‘‘(e) RULE OF CONSTRUCTION.—Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories.’’.

[lillaguma]

Oct 22, 2024 6:23:54 GMT -5 expectantsteelerfan said:

The first thing I ask when calling any new provider is 'do you accept H insurance?' because our insurance is very clear that who is 'in-network' can change and their website isn't always up to date.

The frustrating thing about this is that no one wants to take the responsibility of telling you "yes". I do this because of a past bad experience (see below) and the Dr office will always say, "it looks like we do, but the best thing to do is check with your insurance" and I call the insurance line and they tell me to call the doctor office. I think no one wants to falsely confirm coverage and be liable.

In 2017 I had a health issue, I knew I needed to get in to see a gynecologist. Found someone that could see me that day that took my insurance (I was using Obamacare) and when I went they even took my card and said I didn't have a copay, all that. I ended up having to have emergency surgery the next day with this doctor, it was a mess.

Well then everything came in out of network. Apparently they had been taken off our plan like two weeks before but no one knew there, it wasn't updated, etc. It was December, which may have been a factor. Trying to figure out that headache while recovering from surgery sucked. We had to pay so much money. I remember telling the practice I couldn't come in for my follow up appointment, it was just going to be too expensive and I had all these bills to pay. They were really nice and saw me for free.

[nicolewi]

Oct 22, 2024 11:57:25 GMT -5 lillaguma said:

Oct 22, 2024 6:23:54 GMT -5 expectantsteelerfan said:

The first thing I ask when calling any new provider is 'do you accept H insurance?' because our insurance is very clear that who is 'in-network' can change and their website isn't always up to date.

The frustrating thing about this is that no one wants to take the responsibility of telling you "yes". I do this because of a past bad experience (see below) and the Dr office will always say, "it looks like we do, but the best thing to do is check with your doctors office" and I call the insurance line and they tell me to call the doctor office. I think no one wants to falsely confirm coverage and be liable.

In 2017 I had a health issue, I knew I needed to get in to see a gynecologist. Found someone that could see me that day that took my insurance (I was using Obamacare) and when I went they even took my card and said I didn't have a copay, all that. I ended up having to have emergency surgery the next day with this doctor, it was a mess.

Well then everything came in out of network. Apparently they had been taken off our plan like two weeks before but no one knew there, it wasn't updated, etc. It was December, which may have been a factor. Trying to figure out that headache while recovering from surgery sucked. We had to pay so much money. I remember telling the practice I couldn't come in for my follow up appointment, it was just going to be too expensive and I had all these bills to pay. They were really nice and saw me for free.

This is awful. So sorry that happened.

[starburst604]

Oct 22, 2024 11:57:25 GMT -5 lillaguma said:

Oct 22, 2024 6:23:54 GMT -5 expectantsteelerfan said:

The first thing I ask when calling any new provider is 'do you accept H insurance?' because our insurance is very clear that who is 'in-network' can change and their website isn't always up to date.

The frustrating thing about this is that no one wants to take the responsibility of telling you "yes". I do this because of a past bad experience (see below) and the Dr office will always say, "it looks like we do, but the best thing to do is check with your doctors office" and I call the insurance line and they tell me to call the doctor office. I think no one wants to falsely confirm coverage and be liable.

In 2017 I had a health issue, I knew I needed to get in to see a gynecologist. Found someone that could see me that day that took my insurance (I was using Obamacare) and when I went they even took my card and said I didn't have a copay, all that. I ended up having to have emergency surgery the next day with this doctor, it was a mess.

Well then everything came in out of network. Apparently they had been taken off our plan like two weeks before but no one knew there, it wasn't updated, etc. It was December, which may have been a factor. Trying to figure out that headache while recovering from surgery sucked. We had to pay so much money. I remember telling the practice I couldn't come in for my follow up appointment, it was just going to be too expensive and I had all these bills to pay. They were really nice and saw me for free.

This right here is the most frustrating part. At my office, we always tell people to call and check with their insurance because while we may take X Plan, X Plan has so many different networks under that umbrella that we can't guarantee anything. The insurance company sometimes can't answer the patient, but they sure do know we aren't in network when they process the claim, don't they?! Or sometimes certain providers in our office are in network while others are not - how is that possible when we enroll as a group?! 

It's all such a ridiculous mess and I'm sorry you ended up paying so much. 

[sent]

Oct 22, 2024 8:11:56 GMT -5 Bad Dingo said:

"Starting in 2022, the No Surprises Act requires all private health plans, including QHPs, to maintain accurate provider directories and requires providers to regularly update plans about any changes in their information. Plans must verify and update directories at least every 90 days and, on an ongoing basis, post any changes within 2 business days. Plans are also required to apply in-network cost sharing for covered services provided by facilities or providers mistakenly listed as in-network."

I'd send them this language and demand that you be charged the in-network amount. You could also reach out to your state Healthcare Advocate for advice.

Does this apply to dental insurance?

I just looked up one dental insurance company (the one where Snoopy was the mascot) and found a provider listed as in-network at an address where she has not practiced since before COVID. This was on the first page of results so I stopped looking for more. 

I know another dental insurance company (the one named after a greek letter) where I am an in-network provider and they don't have me listed on their website. I tried to fight this a few years ago and they claimed it was fixed, I learned earlier this year that it was broken again at some point and I wasn't showing up. I already know I have lost business from that error because the person who brought it to my attention (it was a job applicant!) picked a different office for a family member's treatment because I didn't show up on the list when she searched. 

I get notices about the 90 day thing from a few insurances but not from the vast majority. 

[sent]

For the OP, I think you can fight it but be prepared for it to not be easy. I would lean into HR like a previous poster advised. If that doesn't work, then report it to your state insurance commissioner. I've heard stories where that works.

[Bad Dingo]

sent, my non-helpful answer is- it's complicated/it depends.

www.dentaleconomics.com/practice/systems/article/14305840/how-the-federal-no-surprises-act-applies-to-dentists

www.mblawfirm.com/insights/dental-law/the-no-surprises-act-a-look-at-what-dentists-need-to-know/

[sent]

Oct 23, 2024 3:20:22 GMT -5 Bad Dingo said:

sent , my non-helpful answer is- it's complicated/it depends.

www.dentaleconomics.com/practice/systems/article/14305840/how-the-federal-no-surprises-act-applies-to-dentists

www.mblawfirm.com/insights/dental-law/the-no-surprises-act-a-look-at-what-dentists-need-to-know/

I don't think the No Surprises Act will apply to the OP's situation when it comes to dental. Removing baby teeth that won't fall out on their own is rarely an emergency procedure. 

But OP should still fight it because both sides are playing ugly here and enriching themselves at the public's expense. The insurance companies refuse to provide accurate information to providers and policy holders (OP) because they don't have to by law. And the Oral Surgeon's billing group is just being shady AF. OP keeps showing up to the same office and seeing the same doctor, but the money people on the back end change because the doctor sold his practice to some group - how is she supposed to know who owns the office? These groups that are buying offices are also not required by law to tell the public that their dentist's office is no longer owned by the local doctor but is instead owned by one of these private equity backed groups that are swallowing up practices all over the US & Canada. Except in Oregon. I believe Oregon has some law that requires disclosure of who owns the office based on some discussions I follow.

OP, I hate telling people to write Google reviews for doctor's offices. But in this case, I feel like you should. It's one way to let the community know that the office is no longer owned by the local doctor.