Virginia Out of Network, My bad

[JOhn penrose]

Jurisdiction

Virginia

Can medical practice stand to profit by failing to tell patients their practice is out of network, in order to receive non-insurance based payment?

I have very good insurance, UHC POS-PPO.
When I called to make an appointment the first thing they did was take my UHC info. BTW, This group doesnt take UHC.
Day of procedure, they again take my insurance info, copy my cards, and just 10 mins before I go back , they show a form that the insurance will pay 100% or 80% of the bill, I I sign to acknowledge.....after it is over, the copay is $501, no portion of the procedure was covered because they do not take UHC. They know and they knew they were out of my network. Had they told me, they know I would have gone elsewhere..

What recourse do I have....

 

[cbg]

At what time did you contact UHC and ask them if the providers were in network and all of the procedures covered?

 

[zddoodah]

Can medical practice stand to profit by failing to tell patients their practice is out of network, in order to receive non-insurance based payment?

As phrased, the answer to this question is yes, but I doubt this is what you intended to ask.

I'm not entirely sure what you might have intended, but it's your responsibility to ensure that providers you see are "in network," and it's not the provider's responsibility to tell you if it's not "in network."

Day of procedure, they again take my insurance info, copy my cards, and just 10 mins before I go back , they show a form that the insurance will pay 100% or 80% of the bill, I I sign to acknowledge.....after it is over, the copay is $501, no portion of the procedure was covered because they do not take UHC. They know and they knew they were out of my network.

So...are you saying that prior to this unnamed "procedure," you were told by the provider that the procedure would be covered, but then, after the "procedure" was done, you were told otherwise? That may greatly change the conclusion.

 

[JOhn penrose]

As phrased, the answer to this question is yes, but I doubt this is what you intended to ask.

I'm not entirely sure what you might have intended, but it's your responsibility to ensure that providers you see are "in network," and it's not the provider's responsibility to tell you if it's not "in network."



So...are you saying that prior to this unnamed "procedure," you were told by the provider that the procedure would be covered, but then, after the "procedure" was done, you were told otherwise? That may greatly change the conclusion.

Yes, thanks for wording it this way. But this is exactly how things transpired. They LED me to believe that this procedure would be covered. Why would they collect my insurance info twice AND show me a list of possible out of pocket expenses if they knew all along they do Not take UHC.

Do they rake in more money by not going through an insurance company for reinbursement? Thank you!

 

[JOhn penrose]

At what time did you contact UHC and ask them if the providers were in network and all of the procedures covered?

It has been my experience that during an initial contact to make an appt., they screen you for how you are going to pay and if you dont have a way to pay they tell you upfront so as to avoid this very situation.

 

[army judge]

What recourse do I have

Your recourse will PROBABLY not be found in a courtroom.

Read the documents provided by your insurer, buried somewhere among the jumble of words you'll find the provision requiring all disputes to be settled by mediation.

Among the jumble of words found in YOUR contract of coverage the process will be spelled out in meticulous detail.

This is one of your carrier's websites.
You might wish to start here, or log onto your plan's designated site and read all about in-network versus out of network and the issues related to making the proper choice.

Understanding HMO, PPO, EPO, POS plans

I suggest you speak with a customer service representative or write a letter to the carrier informing the carrier of your "mistake" and seeking guidance on what you must do to move forward with as little financial damage as possible.

 

[cbg]

It is YOUR responsibility, not theirs, to confirm who is in and out of network for you and what procedures are covered. If you fail to do so, then yes indeed, your bad.

FYI, I worked for UHC for five years. They have multiple networks depending on the plan design, the number of insured employees and even the employer. It's not as simple as "It's UHC, therefore doctor x is/is not in network". They might be in network for some plans and out of network for others. That's why it is not their job to tell you if they're in network or not. It's yours to call UHC and find out for yourself.