How to fight an unexpected bill under Obamacare

June 20 01:00 2014 by ushadmin

Do your homework.

That’s the advice health insurance companies have long given. They tell you to verify whether your doctor or hospital is in network before you head to your appointments. If you don’t, you risk a hefty bill for visiting an uncovered provider.

But in the age of Obamacare, “doing your homework” has gotten exponentially more complicated. As I have explained in recent columns, many insurers have significantly limited the number of participating doctors and hospitals.

To make matters worse, provider lists have been rife with inaccuracies, and it can be near impossible to get through on insurers’ jammed customer service lines. Even some doctors themselves don’t know which plans they’re on.

Many of you are heroically trying to confirm your provider’s status, but I’m sorry to say some will nevertheless receive unexpected bills in the mail saying the doctor or hospital you visited wasn’t in network after all. It’s already starting, and I predict these bills will become a major problem as more of you seek care.
Today, I’m providing some tips about how to fight out-of-network bills for which you don’t believe you’re responsible …

I purchased an Anthem Blue Cross PPO plan. Before Jan. 1, I checked Anthem’s website for a doctor in network and called the clinic to double-check. When I went to the appointment, I was sent away because the clinic informed me they were not part of the network … I called another doctor’s office twice before I went to see him, and both times I was told they were in network. I kept my appointment, then I received the bill and an Explanation of Benefits from Anthem that indicated the doctor was actually not in the network. How can people protect themselves from incidents like this?

This question comes from Libby Higgs of Modesto, a retired human resources manager — you know, the kind of person who likes to wade through details to hunt down answers. But even Libby barely escaped meeting her match with Obamacare’s “narrow networks.”

Her unexpected bill came to $333, and she protested. Because of the confusion related to this doctor’s status, Anthem agreed to reprocess claims from that doctor through March 31 as if he were in network. That brought her bill down to $108.

Her sister, however, who was referred to a neurologist by her primary care physician, wasn’t as lucky. The neurologist wasn’t in network after all, and now her sister faces a $1,000 bill.

“Before, it was pretty set in stone that if a provider said they were in network, they usually were. There wasn’t a whole lot of doubt,” she said. Not anymore.

Anthem says it has worked hard to increase the accuracy of the provider finder tool on its website since the beginning of the year. Spokesman Darrel Ng says Anthem has asked every medical group for a new roster of doctors who participate in its individual and family plans.

Still, Libby questions Anthem’s accuracy.

She went to the plan’s website on May 31 to search for a podiatrist. “If you just glance at this, it looks like there are 19 podiatrists in my area, and there really are not,” she says.

If you, like Libby, do your homework and still get billed for going out of network, follow these steps:

• Call the plan’s customer service number and ask to get the bill fixed.

• If your complaint isn’t resolved quickly, file a grievance. The law says plans must give you at least 180 days to do so, says Marta Green of the state Department of Managed Health Care (DMHC).

• In most cases, the plan has 30 days to address your grievance. If you’re not satisfied with the response, call the DMHC Help Center at 888-466-2219. Complaints are handled on a case-by-case basis, so that (hopefully) means yours will get some personal attention.

• Build a paper trail. If an insurer’s website tells you a doctor is in network, take a screen shot and save it. If you talk to customer service agents, keep a log. Note the time and date of the calls and ask for each agent’s name.

Once again, beware of rely­ing on the doctor alone to confirm network status, because your financial contract is with the insurance company. If the doctor is wrong, your health plan may not be willing to adjust how much it pays.

Anthem’s Ng confirms this: “Just like any other business, the party who makes the error is responsible.”

But even if you relied on your doctor, you should still call DMHC’s Help Center, Green says. While she can’t promise a positive outcome to your complaint, she notes, “we would like to try to help.”

I asked Libby what she plans to do differently for future doctors’ appointments, given her disappointing first experience.

“I’m trying not to go to any doctors,” she says. “I’m really hoping that by next year, they will have this straightened out and that the doctors I really want to see will be part of Anthem.”