I have HMO/PPO insurance through HealthNet in California. I was using my HMO benefits and got everything approved ahead of time with in-network providers.
I went to my primary and was referred to a specialist to have a growth removed. Got the authorization and was good to go. Had the procedure done at my medical group’s affiliated hospital. The lab results came back benign. Great!
Weeks later, I got a bill from the pathologist. He had submitted the bill to insurance but they paid him based on the out of network schedule because apparently he’s not on the provider panel. Now he says I’m on the hook for the balance.
I called my HMO right away to file an appeal. I was sure it was a mistake, because the doctor who did the procedure was in network, and so was the hospital, and everything was authorized. I had no knowledge or control over who would process the tissue in the lab. What patient would?
Got a letter from my HMO today, saying that my appeal was denied because of the pathologist being out of network.
This makes no sense to me. If anyone had asked me, of course I would have told them to use someone who was in network. Granted, it may have been in the fine print of the reams of paper I signed during pre-admission, but that doesn’t make it right.
Can they legitimately deny payment in this situation? If I pursue it further, am I likely to get anywhere with it?
submitted by /u/catsaway9
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I have HMO/PPO insurance through HealthNet in California. I was using my HMO benefits and got everything approved ahead of time with in-network providers. I went to my primary and was referred to a specialist to have a growth removed. Got the authorization and was good to go. Had the procedure done at my medical group’s affiliated hospital. The lab results came back benign. Great! Weeks later, I got a bill from the pathologist. He had submitted the bill to insurance but they paid him based on the out of network schedule because apparently he’s not on the provider panel. Now he says I’m on the hook for the balance. I called my HMO right away to file an appeal. I was sure it was a mistake, because the doctor who did the procedure was in network, and so was the hospital, and everything was authorized. I had no knowledge or control over who would process the tissue in the lab. What patient would? Got a letter from my HMO today, saying that my appeal was denied because of the pathologist being out of network. This makes no sense to me. If anyone had asked me, of course I would have told them to use someone who was in network. Granted, it may have been in the fine print of the reams of paper I signed during pre-admission, but that doesn’t make it right. Can they legitimately deny payment in this situation? If I pursue it further, am I likely to get anywhere with it?
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