Question:
I am having a hard time with my doctors office..

The situation is this: My surgery is supposed to be covered at 60% because it is a out-of-network benefit...the insurance company is billing as a in-network-benefit because they are saying that the doctors office is sending my doctors tax id through as a general surgeon rather than a specialized tax id for gastric bypass...this would be fine with me if it wasn't for the fact that as an in-network-benefit what I would be charged from the doctors office is considerably less then what I am being charged..so the insurance company is paying out 90% of a charge that is about 4,000.00 less than what I am being billed...I have been going over this with both places for months and still nothing is being done and now of course they are sending me statements from the doc's office saying that they are sending me to their attorney for being delinquent on payment..well I'm not going to pay them until they get this figured out..my question is does anybody know from this point what I should do?? Is this a case to involve a lawyer or is there some kind of an organization that I can go to that could help me to force these companies to get there act together...any advice would be great...feel free to e-mail me [email protected]    — christine L. (posted on January 8, 2001)

January 8, 2001
If the doctor's office is truly billing as if this is an in-network benefit, then they would have to abide by the in-network contract. Usually that means that they have to agree to the reduced fee of an in-network provider. It also means that they are not allowed to bill you for a higher amount than what they are billing the insurance company. Your insurance should be sending you statements saying how much they paid, and how much is left as the "patient's responsibility". Pay that amount to your surgeon, and if he still wants more, tell him he has to re-submit corrected bills to your insurance company before you will pay anything more. If he won't do that, I am afraid he may be commiting insurance fraud.
   — Lynn K.