This whole issue is a big mess from all angles so apologies for the long post but I want to be pretty comprehensive of all the issues I’m facing. I’m in NY and was on a United Health plan via my old employer when all these issues came up. TL;DR is that I’m being billed out of network for a provider that was being shown as in-network on their website among other billing issues.
So last year I had to go to a gastro and ended up getting two endoscopies, one initially to diagnose an issue, and another several weeks later to follow up.
Fast forward to this year and the doctor I went to see filed all the bills in one batch, but several months later. I had these procedures around October of last year, but many of the claims weren’t filed and then processed until recently. In January I had a few pop up but last month I had even more come in. There’s a couple issues that are coming up, in order of priority below and I don’t know how to handle them.
Almost all of these claims are being billed as out of network despite the provider being listed as in network on their website and me being told the entire time that everything was in network. I initially went to urgent care who referred me to this gastro as in-network and the entire time I was told everything was in-network by word of mouth. I have 2 other doctors filing claims under the same 2 surgical procedures, but it appears they’re sort of being counted as in-network? The first endoscopy procedure had both of them come down from like $20k total to $2k total. The second procedure has one of them not being covered at all for a $10k claim because they did not submit credentials they are a doctor according to the latest note on the claim which doesn’t make sense since they accepted their claim for the first surgery I have received none of these actual bills months later. I don’t know if this is normal? I cannot get ahold of the billing dept so I don’t know what I should be doing. I also received a MARS (Medical Audit and Review Solution) notice that showed they audited the claims and found they didn’t follow standard coding practices. I don’t know where this ranks but I really feel like this entire thing is sketchy and I don’t know if they’re trying to cheat me or something. What I do know from my insurance is that this provider has been billing all these claims with an out of network tax ID but refuses to pick up the phone so I can’t get ahold of them to get this fixed
So there’s a lot going on here and I’ve never really dealt with the healthcare system before now so I’m a bit overwhelmed on how to proceed. I’ve had a bunch of back and forth on the phone with my health insurance, and both them and I have been unable to reach the billing department despite reaching out multiple times. I ended up filing an appeal because this provider was listed as in-network and regardless of whether I’ve received the bills or not I don’t see why I should be liable given that my insurance told me this guy was in network.
I received my appeal decision a little over 2 weeks ago and they denied it, claiming they processed everything properly and despite me attaching a screenshot showing him as listed in-network on their website they basically wrote that they are not responsible for info on their website and that I should check with the provider ahead of time.
Where should I proceed from here given all the above? Should I be going to some state agency/board (I’m in NY as an FYI)? Should I be looking at legal help? I want to appeal their decision on my appeal but should I be getting a lawyer to assist me? There’s over $20k of claims being filed with these issues if that helps.
submitted by /u/Kharn501
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This whole issue is a big mess from all angles so apologies for the long post but I want to be pretty comprehensive of all the issues I’m facing. I’m in NY and was on a United Health plan via my old employer when all these issues came up. TL;DR is that I’m being billed out of network for a provider that was being shown as in-network on their website among other billing issues. So last year I had to go to a gastro and ended up getting two endoscopies, one initially to diagnose an issue, and another several weeks later to follow up. Fast forward to this year and the doctor I went to see filed all the bills in one batch, but several months later. I had these procedures around October of last year, but many of the claims weren’t filed and then processed until recently. In January I had a few pop up but last month I had even more come in. There’s a couple issues that are coming up, in order of priority below and I don’t know how to handle them.
Almost all of these claims are being billed as out of network despite the provider being listed as in network on their website and me being told the entire time that everything was in network. I initially went to urgent care who referred me to this gastro as in-network and the entire time I was told everything was in-network by word of mouth. I have 2 other doctors filing claims under the same 2 surgical procedures, but it appears they’re sort of being counted as in-network? The first endoscopy procedure had both of them come down from like $20k total to $2k total. The second procedure has one of them not being covered at all for a $10k claim because they did not submit credentials they are a doctor according to the latest note on the claim which doesn’t make sense since they accepted their claim for the first surgery I have received none of these actual bills months later. I don’t know if this is normal? I cannot get ahold of the billing dept so I don’t know what I should be doing. I also received a MARS (Medical Audit and Review Solution) notice that showed they audited the claims and found they didn’t follow standard coding practices. I don’t know where this ranks but I really feel like this entire thing is sketchy and I don’t know if they’re trying to cheat me or something. What I do know from my insurance is that this provider has been billing all these claims with an out of network tax ID but refuses to pick up the phone so I can’t get ahold of them to get this fixed
So there’s a lot going on here and I’ve never really dealt with the healthcare system before now so I’m a bit overwhelmed on how to proceed. I’ve had a bunch of back and forth on the phone with my health insurance, and both them and I have been unable to reach the billing department despite reaching out multiple times. I ended up filing an appeal because this provider was listed as in-network and regardless of whether I’ve received the bills or not I don’t see why I should be liable given that my insurance told me this guy was in network. I received my appeal decision a little over 2 weeks ago and they denied it, claiming they processed everything properly and despite me attaching a screenshot showing him as listed in-network on their website they basically wrote that they are not responsible for info on their website and that I should check with the provider ahead of time. Where should I proceed from here given all the above? Should I be going to some state agency/board (I’m in NY as an FYI)? Should I be looking at legal help? I want to appeal their decision on my appeal but should I be getting a lawyer to assist me? There’s over $20k of claims being filed with these issues if that helps.
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