Question:
Anyone else have insurance problems?

Has anyone had a problem with their insurance companies paying after you already had approval? Mine paid for the hospital because it was in network, but they are paying hardly anything ($1,000.00) to my surgeon. This is so totally unfair. Any help you can provide would be appreciated!!!!    — JODI020770 (posted on March 18, 2003)

March 18, 2003
Unfortunately, just because they approved doesn't mean that they will provide good coverage. It sounds like they are paying "out of network". I have found that many surgeons are not affiliated with a network and the insurance company assumes that you know that you will have to pay the "out of network" rates for the surgeon. With my insurance, they pay 70% of "reasonable and customary" and I'm responsible for the 30% PLUS the difference between R&C and what was billed. If this is your case, you would be responsible for your out of pocket maximum PLUS the difference between R&C and what the surgeon billed. Some surgeons may negotiate their bills but I don't think that is likely, however, they may set up a payment schedule to make the payment easier. Good Luck
   — Carolyn M.

March 18, 2003
Read your Summary Plan Description! Your insurance compnay may only pay a certain percent of the network rate (what they would pay to a contracted, in-network surgeon.) You can usually be billed the remainder by the surgeon. You should have known this before you had surgery, as it is generally the member's responsibility to know what is covered.
   — koogy