Question
Here?s my situation, I really hope you can help. I am in my early thirties and a few months ago, one morning I started having skipping heart beats and breathing issues. I called my HMO Nurse-on-Call and she told me to immediately head to the emergency room. She gave me a list of hospitals and I went to one of them, checked in, paid the co-pay, and got great attention. They did all tests and contacted the Cardiologist on-call to have him examine the results. They were confident I was not having a heart attack, but very concerned and believed I should immediately call the cardiologist on-call office and make an appointment in the next day or two to have him examine me more closely. They were adamant that I get follow up care as soon as possible. Upon discharge I received a referral sheet with the On-Call Cardiologist office information and instructions to contact him immediately for follow-up care.
I returned home and called the Cardiologist office to make an appointment. The assistant said he could see me tomorrow because he was familiar with my case from the emergency room and also very concerned. I went to the Cardiologist office the next day and filled out all the appropriate paperwork, asked about my insurance and handed her my insurance card with all my information and ID, which she made copies of and returned to me. She then asked for the required co-pay which I paid for, and kept the receipt. The doctor was very helpful and conducted several tests over the next few days involving two more visits, including EKG and stress tests. Each time I visited, I paid my insurance co-pay and receipts. The doctor eventually concluded I was safe and healthy and advised me to contact him if anything changes.
Two months later, I get a letter (not a bill) from something called a ?medical group? that is not the Cardiologist office and not my HMO insurance company, but some third party stating that $3000 in claims have been denied. If I do have an issue, I should file a complaint with my HMO insurance company. I called my insurance company who had no record of the claim or denial, they haven?t even heard of it. The also inform me the Cardiologist is not in the network. I called the Cardiologist who explains that the medical group, which is some kind of intermediary between my HMO insurance plan and the Cardiologist, refused to approve it. In addition, the Cardiologist has NEVER ACCEPTED any kind of HMO insurance! During all this time, I hear others tell me I need a PCP to refer me, but I had never even been to see anyone under this HMO insurance plan yet, I was only in it for a couple moths. Finally I just received a formal bill for $3000 to the Cardiologist for all his services. I have an excellent credit score that I don?t want ruined; yet don?t feel I did anything incorrect!
So, I have called all of these parties, and they keep passing me along. The HMO insurance company can?t do anything because they don?t even have the request. The medical group refuses to pay and says take it up with the HMO. The Cardiologist office keeps passing me to billing who says talk to the medical group. I?m going in circles!
My general impression is the Cardiologist office dropped the ball by accepting my HMO insurance and taking my co-pay, and they need to eat this bill. I should have been told they do not accept HMO insurance prior to them conducting all these services ? if not on the first visit, definitely by the third! Also, the emergency room instructed me clearly to go seek attention from the specialist on-call who was already treating me as soon as possible. Seems, my only other option is to go signup with a PCP and explain this situation and beg to get a retroactive authorization, but I?m not sure that will even be approved!
Help me! I have no idea what to do next. I have no idea how I could have handled my heart problems any better, and when I ask all these entities what I should have done differently, no one seems to have an answer. Who is correct in all this? What is the quickest most efficient way for me to handle this problem? I?m good at handling myself on the phone and getting things done, so I?m not afraid to be stern and demand results. I?ve also been logging my calls and names of who I have contacted.
Answer
Hi Joe!
I would first go back to the Cardiologist and ask why they did not call your HMO on the first visit and advised you that they did not accept your insurance. Ask why did they charge you your copay according to your HMO plan if they did not accept it. Tell them you feel you have been "frauded" and feel this is unacceptable. Explain to them if you were told on the first visit that they did not accept your HMO plan you would have found another Dr. Tell them you feel they "lied" to you on purpose and did not give you the option to find another Dr. Therefore you feel they should "eat" the bill. Perhaps they may or at least reduce it. Worth a shot since really your problem is with this Dr not doing their job.
HMO's are very difficult to fight since they do require you to stay in an HMO network and will not pay for providers/Drs out of their network. Usually there is not recourse when you do.
Remember though it is the patient's responsibility to find out if a provider or Dr is in their network. As a courtesy the Dr/provider should to it but ultimately they do not have to. It is up to the patient to ask and know prior to any service.
Good Luck!
Tricia
