What happens if I didn’t realize the doctor I used was out of network?

UPDATED: Jan 2, 2014

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UPDATED: Jan 2, 2014Fact Checked

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Asked January 2, 2014

1 Answer

During medical treatments, it is not unusual for one doctor to refer you to another, perhaps because you should see a specialist in a certain field. When this happens, you could end up in the office of a doctor outside of your provider network, and that could lead to some financial problems. If you receive a bill for medical services that were performed out of network, there is a procedure to help you get the problem solved.

First, talk to the doctor to find out whether they would be interested in joining your health plan network. If so, you can contact your health insurance provider and they will get the necessary forms to the doctor. If the doctor does not want to join your network, the health insurer is your next logical step.

Contact the insurance company and discuss making an appeal. Most insurers have more than one method of appealing a denial, and your agent can provide you with the necessary forms. Be sure to follow the procedures you are given exactly the way you are instructed, and verify all of the information you provide. Be sure to include a reason why you went to an out of network physician, and document any in-network medical services that are connected to the same treatments.

During the appeal process, which may be anywhere from 30 to 90 days, keep the account active by making small payments. Even amounts of $20 to $50 will demonstrate that you are interested in getting the situation resolved as well as preventing the bill from going to a collection agency. As long as you keep the bill active with the insurer you have a chance of working out the problem, but once it is turned over for collections, your options will be reduced to near zero.

As a last resort, speak to a supervisor with your health insurance company. Explain your case and that you are interested in getting the case closed. If faced with a choice between negotiating the final price or potentially losing payment completely, many insurance companies will negotiate down to very low amounts, sometimes as much as 40 to 60 cents on the dollar.

Answered January 2, 2014 by Anonymous

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