Question:
my insurance is only paying 60% of what they feel is appropriate

I received a bill for $11k from my doctor and a check from the insurance company for $1,200. i called them and they said that since the dr was not contracted they only pay 60% of what they feel is an appropriate rate for the surgery and that i have to pay the balance ($9,800) to the dr. Has anyone else had this type of problem? what was the result? HELP!!!!    — michele T. (posted on November 16, 2003)

November 16, 2003
My friend had the same problem. With her insurance company there was no surgeons in her area. So she went out of network and was billed by both the hospital and doctor for what the insurance wouldn't pay. She took out a personal loan for $18,000.
   — V B.

November 16, 2003
The result? You will have to pay it but see if your doctor won't set up payments in that circumstance. My surgeon wasn't contracted either and my insurance only paid 1600. of his 6000 bill but thankfully I had medicare as a secondary so it was taken care of.
   — Delores S.

November 16, 2003
Did your insurance company approve the procedure as medically necessary prior to the procedure? How was this approval worded? Check your policy and see what they say about in-network vs. out-of-network doctors. If they approve a procedure as medically necessary but have no one within their network of surgeons who is qualified to do the procedure they should have to pay the billed rate...not their "acceptable" rate that they would pay to contracted surgeons. No promises, but this is an avenue that needs looking into. A friend of mine was being billed for about $30,000 of her BPD/DS and once we looked into the policy contract they paid every dime. Good Luck!
   — Theresa A

November 16, 2003
This is very common. Actually alot of policies wont even pay for out of network doctors/hospitals. I don't want to sound mean or anything, but this is something you should have researched prior to choosing your surgeon. Hopefully the hospital you stayed in was in network. When you have a policy that covers out of network doctors they will usually pay less of a percentage and then only pay the percentage on the reasonable and customary charges. Now, what you can do to try and alleviate some of the financial burden.....like what was suggested previously, contact your ins company and see if there was a network doctor that you could have seen. If not, then most insurance companies will pay the entire reasonable and customary. This will still leave the difference between R&C and the billed charges as your responsibility. At that point most surgeons and hospitals will negotiate a discount with you. From my experience they will generally lower their billed charges down to 70%. IF you can convince the ins company to pay R&C and IF you can convince the doctor/hospital to take 70% as the total, you would only be responsible for the 10%. That is a BIG if. Unfortunately either way, im sorry to say, you will have a big bill to pay.
   — RebeccaP

November 17, 2003
The same thing happened to me, the insurance co only paid $1700 of my out-of-network surgeon, and I owe the balance of about $6300. I am going to file an appeal with the insurance co but it's been reviewed and denied once already. FOr now I have set up a payment plan with my surgeon of $25 per month. Not much more I can do, right?!!!
   — beeda