Strange(?) Medical Insurance Situation (Need Advice)

links_slayer
links_slayer Posts: 1,151 Member
in Chit-Chat
tl;dr...sry

Brief Backstory:
CT Scan performed at in-network facility on June 14 2013
CT Scan sent to out-of-network facility on June 17 2013
CT Scan read by out-of-network surgeon on June 19 2013
Surgery performed at out-of-network facility on July 8 2013
CT Scan read by out-of-network radiologist on July 19 2013

So...

I was diagnosed with cancer on June 14 of last year. We went through all of the necessary pre-authorizations since the surgery was going to be done at an out-of-network hospital. A few office visits, pre-surgery appointments, and the surgery itself.

In October we get a bill for $400 for the reading of a CT scan ~2 weeks after my surgery. Weird. Even weirder was that it was done by a doctor we had never heard of, let alone seen at the hospital.

Between my wife and I, dozens (literally) of phone calls were made in order to try and get this figured out. It turns out my surgeon asked his radiologist colleague to read the scan (on July 19) to give him his opinion regarding radiation therapy. The radiologist, in turn, billed it like he normally would for a situation like this.

My primary insurance says this 2nd reading (the reading by the radiologist) is not covered because I didn't receive pre-authorization for it and because it occurred outside a 15-day window from the first reading (June 19). Well...that's interesting because had I known it was going to be read you can bet your bottom dollar I would have gotten it pre-authorized (like I did for EVERYTHING else!). But since I didn't know about it I didn't get the paperwork going.....kinda hard to do when you don't know about it.

The billing department at the out-of-network hospital is saying it's my primary insurance's responsibility to pay for this since they are the ones that sent it to them to get read.

To make matter worse/more complicated(?) I paid the bill at the out-of-network facility since I went 3 months without paying (because I was trying to get it resolved with my primary insurance company....) and they threatened to turn this over to collections. Whatever. I bit the bullet just to get them off my back.

Basically this has all turned into a wicked game of point the finger at the other guy and I can't get a straight answer out of anyone I talk to. Anyone have any advice on how I should proceed - or if it's even worth my time? $400 is such a small drop in the bucket compared to what insurance has paid for the surgery, hospital stay, and radiation, home health care, etc....?

I would greatly appreciate any advice. If you'd rather discuss this privately sending me a PM would be fine.

Replies

  • Excuse_less
    Excuse_less Posts: 874 Member
    The surgeon is not in a position to send out an imaging study for interpretation that wasn't done by him. I wouldn't pay it. You didn't sign anything binding for a second interpretation it doesn't sound like.
  • dbmata
    dbmata Posts: 12,950 Member
    Here's the deal.

    Your doctor broke standards by having the second reading done in that manner. However, it was done to (presumably) make sure that you are getting the best treatment possible. Finally, you already paid it.

    Getting that money back will take more than 4 hours of work, so in my book, I'd chalk it up to the cost of living, and move on.

    I'd say, considering you had/have cancer, the fact that you're still around to deal with this issue is good.
  • Ely82010
    Ely82010 Posts: 1,998 Member
    Sadly and because you already paid, I agree with the above statements. Your doctor should have paid for the reading, not you or the insurance; it is the doctor or his office obligation to know how to navigate and work within the limits of a patient's insurance (HMO or PPO).

    Sorry that you have to deal with this issue, but happy that you are doing so well that you can still post a question in the forums.
  • QueenBishOTUniverse
    QueenBishOTUniverse Posts: 14,121 Member
    You didn't sign anything, you didn't agree to anything, you didn't authorize anything, you didn't approve anything, you never even met with or spoke to this doctor, but he's threatening to damage your credit? There is something screaming unethical and manipulative to me here. I agree that it is very unlikely you will ever get that money back, and the fight it would take probably wouldn't be worth it, but at a minimum I would be lodging complaints with every single oversight organization or authority I could find about this. This was WRONG and you should make an issue of it.

    My 2 cents, was raised by lawyers..... I raise hell if a mechanic does something to my car without prior notification and authorization.
  • tidesong
    tidesong Posts: 451 Member
    It is regular practice for a radiologist to read any medical imaging, whether or not a doctor asked them to. Every single MRI I've had (about 20 now due mainly to my having MS) is first read by a radiologist, who sends his/her report, along with the images, to my neurologist. My shoulder MRI was read by a radiologist, who sent his/her report and the images to my orthopod. Etc., etc.
  • laurynwithawhy
    laurynwithawhy Posts: 385 Member
    Hindsight is 20/20 but really you shouldn't have paid. It's the same as a fraudulent credit card. It wasn't asked for or approved by you, you weren't consulted prior to the 2nd reading taking place. In fact, you could probably make a case for the doctor illegally sharing your medical records with someone who was unauthorized (although those sort of consults take place all the time). Sorry you had to deal with that, insurance companies are the worst.
  • DownsizingAaron
    DownsizingAaron Posts: 127 Member
    My local paper has a "watchdog" section where they take on issues that are unfair to consumers. I bet this happens more often then we know... would be a good story for the media to work on. I would think with all the talk about healthcare this year that someone locally would bite on this story. You're a lot more likely to get somewhere with them on your side!
  • MyFoodGod
    MyFoodGod Posts: 184 Member
    Have you called the surgeon's office and asked if this is common? Don't be too angry or defensive.

    It's also possible you have signed some permission for him to get a second opinion.

    If you are happy with your treatment you don't want to become a problem patient. You don't want to find it's hard to get an appointment.

    Yes it sucks but too much stressing about it isn't good for your health either.

    Wishing you good health.
  • 17ChargerGirl17
    17ChargerGirl17 Posts: 441
    Ok, so since I am a Billing Supervisor and I do medical billing for a living, I will do my best to answer this question.
    The Radiologist bill is a separate bill than the hospital or physicians. (this is also the way it is with labs as well) Any scan or x ray that someone has done, has to be read by an accredited Radiologist. You're dr can look at it and make an assumption, but it will always go to a Radiologist. Normally, there is a sign at the imaging center that explains that there could be a bill from the Radiologist. When you went in and had the surgery you signed a bunch of paperwork. I can pretty well guarentee you that it says in the paperwork that there could be an assistant surgeon used and that test are sent out to be read. Having said that, the billing company that is sending you the bills, needs to appeal the decision that they denied the claim since they are saying that your primary should pay it. You also say the second reading done by a Radiologist. Who read it the first time that you were charged for? Feel free to PM me if you want to talk about this more. I'm sorry you have to go through all of this.
  • devil_in_a_blue_dress
    devil_in_a_blue_dress Posts: 5,214 Member
    I was diagnoised with cancer-y looking cells in October 2013 after a routine check up. Had a biopsy (bad cells found). Had surgery. Surgery results did not match biopsy results (no abnormality found). Biopsy and surgery results were interpreted by two seperate pathology labs. Biopsy was done at an outside lab, surgery sample by a hospital pathologist. Doctor ordered the biopsy sample be sent to hospital. When the same arrived from the outside lab, the pathologist on duty read it. This was not the same pathologist who read my surgery biopsy, but agreed with the outside lab. My doctor was like no, I want one set of eyes to look at EVERYTHING.

    My doctor had a friend of hers review everything at once to try and figure out WTF is going on.

    The friend billed my insurance. My insurance was like :huh: because the biopsy result was reread by the pathologist on duty when it arrived and they don't cover 3rd opionions. As soon as my doctor was made aware of that situation, SHE took care of the issue with the pathologist. I would be after you doctor.
  • QueenBishOTUniverse
    QueenBishOTUniverse Posts: 14,121 Member
    Ok, so since I am a Billing Supervisor and I do medical billing for a living, I will do my best to answer this question.
    The Radiologist bill is a separate bill than the hospital or physicians. (this is also the way it is with labs as well) Any scan or x ray that someone has done, has to be read by an accredited Radiologist. You're dr can look at it and make an assumption, but it will always go to a Radiologist. Normally, there is a sign at the imaging center that explains that there could be a bill from the Radiologist. When you went in and had the surgery you signed a bunch of paperwork. I can pretty well guarentee you that it says in the paperwork that there could be an assistant surgeon used and that test are sent out to be read. Having said that, the billing company that is sending you the bills, needs to appeal the decision that they denied the claim since they are saying that your primary should pay it.

    This makes sense, but I think what is making people suspicious is that this consult was done AFTER the surgery took place, and it STILL shouldn't be his responsibility to pay it. If HE is going to be billed for it, HE needs to be consulted first, directly, not stacked somewhere in 10 pages of fine print and BEFORE the consult takes place.

    How would this be different from a mechanic running unathorized diagnostics or making unathorized "necessary" repairs, running a bill up to $400 and then saying "well we did the work, so pay or we'll ruin your credit"? There are laws on the books in most places about exactly this sort of fraudulent and unethical practice being pulled by mechanics too.

    It may be SOP for medical billing, doesn't make it not a shady situation.....
  • QueenBishOTUniverse
    QueenBishOTUniverse Posts: 14,121 Member
    I was diagnoised with cancer-y looking cells in October 2013 after a routine check up. Had a biopsy (bad cells found). Had surgery. Surgery results did not match biopsy results (no abnormality found). Biopsy and surgery results were interpreted by two seperate pathology labs. Biopsy was done at an outside lab, surgery sample by a hospital pathologist. Doctor ordered the biopsy sample be sent to hospital. When the same arrived from the outside lab, the pathologist on duty read it. This was not the same pathologist who read my surgery biopsy, but agreed with the outside lab. My doctor was like no, I want one set of eyes to look at EVERYTHING.

    My doctor had a friend of hers review everything at once to try and figure out WTF is going on.

    The friend billed my insurance. My insurance was like :huh: because the biopsy result was reread by the pathologist on duty when it arrived and they don't cover 3rd opionions. As soon as my doctor was made aware of that situation, SHE took care of the issue with the pathologist. I would be after you doctor.

    Because that is how this situation SHOULD be handled, you know, ethically, not treating a patient like a cash cow. This wasn't the OP's fault, and it wasn't even the insurance companies fault (as much as I love to blame insurance companies), that was an unauthorized consult that the insurance company and OP were NOT given the opportunity to authorize.
  • 17ChargerGirl17
    17ChargerGirl17 Posts: 441
    Ok, so lets clarify a few things here. When exactly was the scan done that you are getting billed for by a dr you have never heard of? I'm also curious about the statement that says they are being billed a second time by a Radiologist. Who read the scan the first time? There should be two bills for that scan. One for the facility where it was done and one from the Radiologist who read it. If it was initially read by a Radiologist and then your physician had a collegue read it after, you need to go to your surgeon and tell him that they are billing you for this. As your surgeon he should go to his collegue and say something.
    And none of this is unethical to do. I'm sure the surgeon didn't do this to screw anyone. More likely to make sure that the diagnosis was correct and the correct steps were being taken to save a life.
  • QueenBishOTUniverse
    QueenBishOTUniverse Posts: 14,121 Member
    I would say unethical if they refuse to work with him to fix it. If the surgeon actually helps fix it then great, but from the OP it sounds like there is a lot of refusing to communicate and pay up or else threats going on, which is unethical.

    To be clear, the original intent behind the consult might not have questionable, but sticking him with the bill when/if he was not properly informed and given the option to refuse, to me, is unethical. Doesn't mean it's illegal, the doctor may be well within their legal rights to do it, but I would still call it unethical.
  • Lleldiranne
    Lleldiranne Posts: 5,516 Member
    This kind of thing actually isn't that strange … the doctors are (presumably) acting in the best interests of the patient by having an expert consult, and the billing gets messed up. We've had that several times from hospitals that are in network but some of the physician is out of network. (Yeah, makes no sense, does it). Then the insurance says they don't have to pay, and of course it's the patient who ends up losing out and having to foot the bill. :sad:

    Since you've already paid it, I wouldn't go through the time and effort to fight it any more, because chances are you won't win any way. But for future reference, I believe that if you are disputing part of a bill, they can't send you to collections (I'm not positive, so look into it more before taking that for advice). But again, in the end, I don't know if it would matter since chances are you'd be stuck with it anyway :(

    I'm sorry you went through this.

    On the other hand, like someone else said, the fact that you've survived cancer and are here to argue it is good. Hopefully you are in full remission or will be soon. :flowerforyou:
  • MyFoodGod
    MyFoodGod Posts: 184 Member
    Once my doctor sent lab work to a non network lab. My insurance company paid it since it was out if my control/ I didn't walk into a non network place. Also if you have insurance thru an employer sometimes HR can help before you pay the bill with understanding options.

    Grateful for good insurance and knowledgable HR benefits staff.
  • leadslinger17
    leadslinger17 Posts: 297 Member
    When our second son was born it was extremely quick. We were at home at 3:30 and he was born in the hospital at 3:56. My wife barely made it to a room. So when we got the bill, there were things like fetal heart rate monitor that we were billed for, but did not have. We disputed it. We requested itemized bills to check item by item. We asked to find out who the nurse was on staff that night that basically just put on gloves and caught our son (haha) to verify that we didn't have any equipment hooked up, there wasn't time.

    But it didn't matter, we didn't get the money back. Getting that money back will take you hours and hours of time, and even then it might just come down to your word against theirs. Are you going to sue them to get the money back? Is your doctor going to testify in court that he didn't ask your permission for the consult? Unless you really have an ax to grind and just want to prove a point (even if you end up losing), unfortunately it will be way more effort and time than its worth. And really if you like the doctor and want to continue working with her, you probably don't want to alienate her.

    Just to add: if money is tight, and the difference of a couple hundred dollars is important. It is best to ask up front for an itemized list of what you are having done (assuming there is time and it is not an emergency situation). Ask your doctor questions (how much is that going to cost, and why do you think I need it?). Let the doctor know up front that you aren't questioning his/her judgement but in your financial situation you might have to veto certain things just because you don't have the money and do not want to be billed for them. You might feel a little uncomfortable/embarrassed, but it is the only way to avoid these types of situations.

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