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  1. #1
    Join Date
    May 2009
    Posts
    1

    Default NICU Out of Network

    My question involves insurance law for the state of: Texas

    My question deals with BCBS denying insurance claims from the NICU due to the doctors that manage the NICU not being in network with my insurance company (BCBS) due to low reimbursement rates. My wife went into pre-term labor at 7-months and was admitted to the antepartem department at our hospital. We had to be admitted to the hospital at 1am due to the preterm labor conditions being so severe. During admission, my wife who was in extreme pain had to sign all of the admission paperwork. Me, as her husband, was not allowed in to assist her due to HOEPPA laws according to the charge nurse. At 11am the next day, her doctor delivered the baby 10-weeks early at which time our daugther, being born at 3.5lbs and 10-weeks early, was admitted to the NICU within the same hospital. Our daughter stayed in the NICU for 47-days. Here is the problem. My wife's doctor and the hospital itself is in network with our insurance provider, Blue Cross Blue Shield of Texas. All bills from those two entities were paid. However, the doctors that cared for my daughter in the NICU choose not to be in network with BCBS due to what they claim is unusually low reimbursement rates. When there bill was submitted to BCBS it was paid out of out network rates. I was balanced billed for approximately $50,000. In researching this issue, I learned that my wife while being admitted (recall that she was in extreme pain) signed a form that detailed that his particular doctor group was most likely not in our insurance network. I have appealed the issue to BCBS and they have denied paying any more to this group. In discussing the issue with the doctor group directly, they have either offered me 20% off the bill or the opportunity to join a class-action lawsuit against BCBS and they will foregive the bill. At this point, I cannot join this suit as BCBS also provides insurance to other employees at the bank I run and therefore "cannot bite the hand that feeds us".

    My question is this. Do I have any recourse against anybody in this situation? I feel the hospital made my wife sign forms under duress that morning, the insurance company evidently reimburses at lower than national averages for this speciality care and the doctor group is being unreasonable in joining the BCBS network despite numerous attempts. Thank you for the feedback.

  2. #2
    Join Date
    Mar 2008
    Posts
    1,995

    Default Re: NICU Out of Network

    I'm sorry to hear about your plight, and it seems the "medical providers" are trying to use the patients as a "pawn" in their fight with the "insurers".

    I know this is a "legal board", and the issued are limited to "should I fight this as a collection item", and what was the contract signed when she entered the hospital, in pain, and is expected to read and understand every last word and paragraph.

    I signed document when I entered the hospital for an emergency, agreeing to be liable personally for portions of the bill my insurer failed to pay. As it turned out, the insurer did pay the hospital based on their contracted rate with the hospital, who promptly placed me for collections for the remainder.

    What I learned later was it was NOT EVEN LEGAL for the hospital to sue the insured covered under medical plans here in NY State, and the document they gave me to sign was unenforceable.

    Instead of treating it as a "collection matter", I contacted my local newspaper, that has a "Money Matters" section in their Sunday papers, and I treated the issue as a "public interest" matter. As a collection matter, the "medical providers" can hide under the cloak or privacy, aracane contract clauses, and no one would know or hear anything about their attempted machinations.

    In fact, my next step would have been to contact my State Senator and Assmeblyman, which proved unnecessary. As it turned out, in my state, your can have a situation where a patient is wheeled into surgery, there would be five medical professionals in the room to do the surgery, three of them would be on the plan, and two of them not. The patients would then get balance bills for those two not in the plan, and patients in surgery are supposed to determine who in the room is on the plan, and who is not, while under sedation.

    If you guessed the hospital dropped it's collection against me, you're right, because the newspaper was going to do a followup story about the hospital taking it's patient to collections even though they were paid in full.

    Think about it for a moment. Do you think what the doctors are doing to you, they want to be publicized in the local papers? In the papers, it's not a matter or what's legal, it's what what is right.

    Right now my state legislature is looking into all these "GOTCHA's", and you might want to take a look see what can be done if you take it to these other "non legal" avenues in your state.

    And with all the talk about "ObamaCare", having everyone one insured. What good is it to anyone if you go into the hospital, with your ObamaCare card, and you get a balance bill from the hospital, say for $50,000, after you leave saying "Sorry, the other part of the hospital is NOT under the plan, didn't you check into that when you were wheeled in like you're SUPPOSED to"??

  3. #3
    Join Date
    Oct 2006
    Location
    supratentorial region
    Posts
    818

    Default Re: NICU Out of Network

    OP, your problem is different than SChin's. In his/her case, the provider (hospital) was paid their contracted rate and attempted to balance bill him. Their contract with his insurance company prevents them from doing so, legally.

    In your case, the NICU Docs were not contracted by BCBS, and you wife was given that information BEFORE she signed the agreement (which IS legally binding). A hospital cannot force all admitting providers to accept certain insurance plans, especially given some of the ridiculously low reimbursement rates for the services they provide.

    The part I find disturbing, although I don't know if it's illegal, is their offering to forgive your balance if you join their class action lawsuit against BCBS. That seems to be the issue that I'm hoping one of the legal experts can answer for you.

    Congratulations on your little one. Best of luck to you.

  4. #4
    Join Date
    Mar 2008
    Posts
    1,995

    Default Re: NICU Out of Network

    Quote Quoting lealea1005
    View Post
    The part I find disturbing, although I don't know if it's illegal, is their offering to forgive your balance if you join their class action lawsuit against BCBS. That seems to be the issue that I'm hoping one of the legal experts can answer for you.
    The disturbing part is it may or may not be legal, and it may even border on being legal. The OP can have the best legal minds working on it and come up with the perfect answer "for him", and is not going to help the "community at large" one bit. The next person going into that hospital in pain is not going to read every last word or what he or she signs, and then another sucker gets stuck paying another $50,000.

    When will it end??

    NOT EVERY circumstance is the same, and I'm not saying my circumstance is exactly the same as the OP, but I could've quietly let them take me to court and have the judge dismiss the case. In that case, what public purpose would it serve??

    The NY State legislature is looking into these situations, especially cases where people are wheeled in in emergencies, in great pain going into surgery, and then have to think carefully "I wonder if every floor of the hospital and every doctor here is on the plan, or are floors and doctors not on the plan tagged another color, say "purple"??

    The argument seems to be the doctors aren't making enough. OK, maybe they are not making enough. But I just see a few posts here every month with people going to hospitals that is "part of the plan", then find a section of the hospital that is not, or 3 out of five doctors in the surgery room are in the plan, and 2 are not. Apparently this does not sound outrageous, and patients are the ones blamed for not reading the plans carefully, or if wheeled into emergency, the patient has to say "wait, have the ambulance take me by my house so I can review the plan first".

    In any other business, this type of chicancery would be outlawed, and perpetrators locked up, except for hospitals and doctors. Because it's a health care issue apparently, it's the stupid patient at fault, and the poor doctors aren't paid enough.

    Unfortuately, the conventional wisdom is to go see a lawyer and see if this is all legal. Big whoop. What is needed is an angry state legislator, or an angry news columnist to blow this type of behavoir wide open, and say "we're not going to take this anymore".

  5. #5
    Join Date
    Oct 2006
    Location
    supratentorial region
    Posts
    818

    Default Re: NICU Out of Network

    Large University teaching hospitals are a better bet for having all the Docs on plan. The clinical professors are ususally salaried employees of the hospital or university.

    I, personally, understand the frustration of being in an emergent situation and later finding out one of the treating Physicians wasn't on plan. When one is unconscious, it's kind of hard to ask questions or refuse care.

    It's very hard to compare any other business with the expertise and education needed to be a NICU Doc ( or, really, any other Physician). Any other business charges as they see fit. If they choose not to sign a particular contract because they will be reimbursed pennies on the dollar, so be it. The customer is free to take their business elsewhere. Soooo, you would lock up a business owner because s/he doesn't abide by a contract they did not sign?

    As for OP's situation....his wife DID sign an agreement. She was aware that the NICU Docs did not contract with her insurance company. I totally understand the situation she was in, and in that case, would have signed the same agreement myself.

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