Question:
Has anyone been successful having an out of network provider paid as in network?
The good news is that I have been approved and I have a date. The bad news is that it is out of network. My insurance has a clause that under certain conditions (like proving that no in network doctor can perform this surgery) they will cover it as in network. My qestion is...does anyone have a sample appeal letter that they would share with me. I appreciate any help. — Lynda D. (posted on January 3, 2003)
January 3, 2003
Congrats on your date.
Just a FYI, yes you can have an out of network provider paid as in-network
if that practice is willing to accept the payment. Most cases, in-network
providers take a big discount compared to what they can be paid for as out
of network. So bascially out of network, the surgeon can collect the
deductible, coinsurance amount as well as any dollars over the usual and
customary fee allowance, allowing them to recoup 100% of there fee. So if
your surgeon is willing to take the cut then go for it. Just to let you
know.
— Jeana S.
January 3, 2003
You shouldn't need a appeal letter at all. There should be a premade
Referral paper that your physician fills out and sends to the insurance
company. The odds of you bieng the first patient seeking surgery through
the out of Network facility is pretty low and there will probally be a
standing procedure in place for this issue.
— Rebecca B.
January 3, 2003
My plan has a clause that states that if there is no speciality provider
w/in a 25 mile radius, it will pay non-network providers as in network.
However, since the provider is not contracted with the PPO plan, they are
not obligated to accept the In Network amount as payment in full - they can
still bill you for the difference. I would chekc with your provider and
see if they would be willing to accept the in network contracted amount as
full payment. It really doesn't hurt. I was lucky that my hospital and
doctor both agreed!
— Rosario T.
January 3, 2003
Hi, this doesn't apply to the surgeon, but was something I had read about
on here prior to my surgery. My surgeon was in-network and so was the
hospital, but his assistant was not and neither were the 'hospital
doctors', a new category for doctors who don't have regular offices or
patients, but just see folks who are in the hospital. Someone had posted
here that they were able to get their insurance to pay for non-network
providers as if they were in-network, since they (the patient) had no say
in who those providers were. My brother called my insurance company and
made that argument to them, without my asking him to, and they agreed.
That saved me quite a bit. I still had to pay the difference between what
the out-of-network providers charged and what my insurance considered their
maximum payment, but my insurance paid 80% of that (in-network rate) as
opposed to only 60% (their out of network rate).
— garw
January 3, 2003
Hi,
My surgeon is out of network and they "work a deal" with each
sugery directly with the insurance company. Talk to whoever handles the
insurance in your dr's office. My dr's staff handled it all for me..Best of
luck....
— Sharon1964
January 3, 2003
I traveled out-of-state for my WLS. Both my primary and secondary
insurance providers paid in-network rates to the out-of-network surgeon,
assistant, anesthesia service and hospital because there was not another
board-certified bariatric surgeon with comparable qualifications who was
any closer to me than this particular surgeon.
— Diana T.
January 5, 2003
This is the original poster. Again, I have to say thanks to everyone for
all the input I received. I have been coming to this board for several
months now, and my journey has been full of roadblocks. This board and the
message board has been a great source of information and support.
— Lynda D.
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