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gertdog
04-03-2006, 12:37 PM
Grrr.... just need to vent a little! This is long- sorry.

Our health insurance allows for an annual eye exam with an in-network provider. So, when we joined the health plan in 2002, we used the insurance company's provider directory to select an optometrist and went to him for 2 years. Then he sold the practice and moved out of state, and we went to the doctor who bought the practice, who told us he accepted our insurance. And, indeed, our claims from the eye exams with the new doctor were processed and paid by our insurer.

We had no problems until last week, when my husband received a notice from our insurance company saying his eye exam two weeks ago wasn't covered. He called today to find out why, and they say it's because the current optometrist is not, and never has been, a member of the insurance plan. Why did they pay the previous claims? They don't know, but they say it was our responsibility to find out if the doctor is a plan member. Well, we did ask him, and he said yes (and accepts our co-pay every visit!), but I understand that we probably should have verified with the insurer as well. So now the insurance company says we have to pay them back for the past two years' worth of claims.

THEN, we get another call saying we also have to pay for the 2 years of claims for the FIRST doctor because his membership expired in 2000, two years before we started seeing him! At this point my husband said "But we found him through your provider directory in 2002." The rep basically referred him to the "fine print" which says that there is no guarantee that the info in the directory is up to date, and that it's our responsibility to determine if a doctor is a member of the insurance plan.

So- we found the first doctor in the insurer's directory of providers. The doctor said he accepted our insurance, accepted our insurance card on each visit, and was reimbursed by our insurance company. How exactly would we be able to determine that he was NOT a member of the insurance plan???

And I just checked the 2006 provider directory- the doctor is still listed!!! SIX years after his membership expired, and two years after he moved out-of-state. GRRRRRRRRRRRRRRR. :mad: :mad: :mad:

I'm getting ready to call and talk to the insurance company, but needed to blow off some steam here first so that I can be cool, calm, and collected on the phone. Thanks for listening! :o

dreamer
04-03-2006, 12:45 PM
I'm sure I'm being too hotheaded here, and someone else may have a more levelheaded solution, but if you have a lawyer I'd consider getting legal advice. This is just CRAZY!!!!!!!!!
Well, I guess first you can consider the appeals process that insurers have; we have used it successfully.
Maybe it'll help you at least feel better to know someone else agrees that this is one of those times when the modern world is acting insanely.
Good luck to you in standing your ground.

Beth
04-03-2006, 01:05 PM
Print the screen or list that shows the doctor still listed as a provider and retain a copy in your records.

I'm not sure off the top of my head, but I would consider making a complaint for deceptive trade practices with the insurance regulator in your state and look at whether this would fit the requirements for a private DTPA claim -- usually requires you to make a written demand to resolve the matter, specifically mention the DTPA or whatever your state calls it and give the specified period of time to resolve it.

Less work on your part, but also possible is making a complaint with a media consumer advocate. I'm sure they'd have fun with this.

The error is theirs. They misrepresented their covereage and they need to live with the consequences. DO not pay the difference.

DmOrtega
04-03-2006, 01:11 PM
Boy... this sounds like a tough issue. It's basicly between the insurance company and you. The dr has been paid, so has no interest in this situation. I think that there must be some recourse given the time period that has come and gone and that they have been approving the charges to payment. Are we expected to contact the insurance company anytime we make an appointment with the dr? What if they don't renew between making the appointment and actually being seen by the dr? There must be some good-faith rules to follow.

gertdog
04-03-2006, 01:26 PM
Thanks all for verifying that I'm not overreacting!

Beth- thanks for the idea of printing out the provider directory. I did that and also saved a copy to my hard drive (it comes as a dated .pdf file, which is helpful).

mbrogier
04-03-2006, 01:31 PM
Mentioning governing boards does do wonders. I think that you verified the doctor's enrollment to the best of your knowledge. What else is the insurance company expecting you to do? I'd be calling whoever handles these types of situations in your state. They should take care of this within the month.

Laurielee
04-03-2006, 01:32 PM
Stephanie, your state should have some kind of state insurance commision that can help you. That sounds so wrong.

I had a problem with our insurance a few years ago, under our cobra plan. Mysteriously the only thing I wasnt recieving on a time basis was our bill. You have a certain time frame to pay it and if you dont, the cobra expires, so our policy expired. I went round and round with the insurance co. They said it was my responsility bill or not to pay in the time period. I went to the Calif state insurance commision. they were helpful, said I was not responsible, sent a letter to the insurance co and it was resolved t my benefit.

I just looked in the phone book under State and found it under State insurance commission and called them.

Laurie

srahndennis
04-03-2006, 02:07 PM
Is your insurance offered through one of your employers? If so, I'd contact the Benefits department to see if they might be able to help. Ridiculous!

imloulou
04-03-2006, 02:09 PM
Stephanie, your state should have some kind of state insurance commision that can help you. That sounds so wrong.
Laurie

This is exactly what I was going to say. I bill insurance companies for a living (massage therapy). We had a case like this where the insurance co. paid for a period of time and then stated the patient was not covered for services. They originally said that we owed back what they had paid. I called them, told them if the insurance company had made one or two mistakes that would be one thing and I would be willing to pay it back...but we are talking a half a year here (2 years for you :eek: ). After one phonecall they changed their mind and agreed that we should not have to pay.

If they dont work with you I would call/write the insurance commissioner and explain your situation.

also...Document Everything!!!!! Names, times, what was discussed, etc!

Good luck!!!!!!

leebee
04-03-2006, 03:25 PM
If you are indeed in New Jersey, here is a link to the state Dept of Banking and Insurance, which should give you some information. I just happen to need to refer to these in the course of my job.

NJ Dept of Banking and Insurance (http://www.state.nj.us/dobi/)

LakeMartinGal
04-03-2006, 04:17 PM
The dr has been paid, so has no interest in this situation.
Actually, the doctor may have some interest in this -- he misrepresented himself to you as part of the network, and he'll definitely lose patients if he's not in the network. Perhaps you could ask him to join the network, and see if they (the insurance company) will accept that.

I would also go to the insurance commission -- great idea! And a consumer advocate is also a fine idea. Pull out all the stops! You are in the right, here!!!

Good luck to you! :)

clairea
04-03-2006, 05:02 PM
How frustrating. Insurance companies make lots of mistakes. I am firmly convinced that they also make lots of "mistakes" to avoid paying claims, as most people either do not know what they are entitled to under their plan, or do not have the time and energy to devote to fighting for it. I get 10-12 EOB's a week for DH and DS, and I would guess at least 1/3 of them have an error. I would do the following:

Make sure you have good records. Print out a screen shot of the provider directory, as suggested, and keep a copy of the hard copy from 2002 if you still have it as well. Keep copies of all correspondence, and notes from all telephone conversations including names of people you talk to, times and dates.

Begin by calling the dr's office, and confirm whether or not they are, or have been, providers under the plan. Sometimes a provider will get improperly coded for one or more visits. Don't just talk to the person who answers the phone, ask to speak to the business manager, explain what has happened, and ask for their help. Also talk to them about what you can do about the outstanding bill. Providers have different policies on how they will handle an insurance dispute (some will give you a fairly lengthy grace period to get it resolved, others ask you to go ahead and pay them and then pursue reimbursement yourself) and to be honest I can see both sides of that issue. Also, if the doctor is a provider under the plan, they will probably have much better luck getting this resolved with the insurer than you will so see if you can enlist their help.

If the dr. really wasn't on the plan, then for the current visit I think unfortunately you are probably out of luck with the insurance company. Doctors drop in and out of plans, and the documentation unfortunately is not kept up to date. If the doctor's office told you they were on the plan, or confirmed your insurance at this visit, billed insurance, and never told you they didn't accept it, or something like that, then I think you have grounds to try to work out a compromise with the doctor's office but in my experience out of network is out of network (unless there truly is no in-network provider available). They want to get paid something, and if you point out the error of their ways to them, they will probably be willing to work with you.

For the older visits, did the insurer pay the doctor's office? If so, then they ought to be seeking reimbursement from the doctor's office. I don't know how frequently this happens, but it certainly is not unheard of for an insurer to reverse a claim and require reimbursement from a provider. I have never had an insurer demand reimbursement from me for amounts paid in error to a third party, they always work it out with the doctor/hospital.

Threats of a report to the insurance commissioner or legal action can be effective, but I would save them for a last resort. Don't get upset with anyone, and if anyone insists that they can't help, ask for their supervisor. I have generally found that when they are indeed in the wrong, the insurer will back down as soon as you show them that you won't (which will probably take 2 or 3 phone calls).

boisewinesnob
04-03-2006, 05:31 PM
For the older visits, did the insurer pay the doctor's office? If so, then they ought to be seeking reimbursement from the doctor's office. I don't know how frequently this happens, but it certainly is not unheard of for an insurer to reverse a claim and require reimbursement from a provider. I have never had an insurer demand reimbursement from me for amounts paid in error to a third party, they always work it out with the doctor/hospital.


I agree with EVERYTHING clairea said, but particularly this. If the insurance paid the doctor, then they need to take it up with him. Many doctors and hospitals having time limits over how long an insurance company can decide that they paid in error and want a take back. I work for the billing dept of a hospital and see it all the time (as well as times they should have paid and didn't for whatever reason).

If you have verified your coverage with both the insurance and dr before your visit, then you have gone through reasonable steps to make sure you are going in-network.
This isn't United Healthcare, by any chance is it?