Are in-network health-care providers allowed to use out-of-network services?

[shira]

I'm covered by a "Health Reimbursement Account" insurance plan. Under this type of plan, if you accumulate a threshold amount of in-network expenses, the insurance company will pay 100% of all in-network costs for the rest of the plan year. I went over the threshold in early December, so I quickly scheduled a colonoscopy, since it would be 100% paid for by my insurance.

As expected, the Explanation of Benefits (EOBs) (for the gastroenterologist, for the hospital room, for the lab work) I received from my insurance company showed 0 as "Patient Responsibility." So you can imagine my surprise when I received this week an EOB for the anesthesia indicating that I owe over $700. For some reason, the gastroenterologist used an out-of-network anesthesiologist, and of course out-of-network health-care providers aren't bound by network pricing.

But my question is: Can a patient really be screwed over like this? Isn't the reasonable assumption that when you go to an in-network physician, all services "radiating" from the physician will also be in-network? I mean, it's almost impossible for a patient to control this type of thing.

Frankly, I'm outraged, and I'm seriously considering refusing to pay. I think I'm going to assign the bill to the gastroenterologist; it was HIS mistake, after all. And why shouldn't he pay for his own mistake?

Anyone have any knowledge of this type of thing?

 

[Gibson486]

I have seen it happen on a few occasions. It's why I liked HMOs. Yeah, you have to get everything approved by your PCP, but once it passes that, you are covered.

 

[Meghan54]

But my question is: Can a patient really be screwed over like this?

Yes, you can.

Isn't the reasonable assumption that when you go to an in-network physician, all services "radiating" from the physician will also be in-network? I mean, it's almost impossible for a patient to control this type of thing.

You'd think so, but then again, you have to understand the "scratch my back, I'll scratch yours" mentality that goes on behind the scenes with physicians. One will refer to another because of friendship, or any other mundane list of reasons. It is incumbent upon patient, unfortunately, to ensure any referrals his/her primary physician makes is also in the network. This can include labs, X-rays, etc. Otherwise, the primary may simply refer a patient to a lab, radiology clinic, specialist with which he is comfortable using without a thought about network affiliation.

Frankly, I'm outraged, and I'm seriously considering refusing to pay. I think I'm going to assign the bill to the gastroenterologist; it was HIS mistake, after all. And why shouldn't he pay for his own mistake?

Anyone have any knowledge of this type of thing?

Not the primary physician's mistake, unfortunately, and just trying to dump the bill back will end up getting you put into collections. As mentioned previously, the patient has the unfortunate duty to ensure any and all physicians, referrals, labs, etc., the primary may use are also in the pt's network, not the other way around. Sorry it works this way, but it does. Welcome to health care for profit and the horribly splintered ins. network system we try to function within.....usually with rather poor outcomes.