out of network costs when no in network doctors exist

[Guest outofnetwork]

Need help from anyone who has been in this situation. I recently underwent an operation, and 2 months after the operation, I come to find out that the anesthesiaologist who administered my anesthesia was an OUT-OF-NETWORK provider, and now I'm faced with medical bills cause the insurance only covers 80% after a deductable is paid. I had asked everyone (my doctor, admitting staff at the hospital) if the insurance would pay everything. No one told me there were no in-network anesthesologist at this hospital!. Thanks! email to softwaredynamics@hotmail.com if you know what my rights are??

[jeanine]

Your rights are going to depend on how you receive your coverage--group health plan insured, group self-funded, individual policy. Check your policy to see what type of appeals process the plan allows then follow it. You have a fairly reasonable argument that this should be paid for a couple of reasons. First, you state that there is no in network anesthesiologist. Second, even if there were, this type of service is not one you can control by choice. Your anesthesiologist is whoever the hospital assigns to you.

[Sandra Pearce]

This would not be considered in our health plan. We have a basic benefit % that is paid for eligible medical services. We increase that benefit, pay a larger %, for a provider in our preferred provider network. We are able to pay the larger amount on those claims because of the discount arrangements which reduce our cost. That discount is shared with the employee in the form of a larger % reimbursement. We never pay the larger in-network % for providers that are not in the network. Many anesthesiologists, pathologists and radiologists refuse to participate in networks simply because they have, for the most part, a captive audience.

[Larry M]

Your plan may state it will pay for any services rendered by an out of network provider if the services were prescribed by an in network provider.

In these situations, the question then becomes what portion of the out of network provider's fee is covered. The document will state whether it accepts the fee charged by the out of network provider as "reasonable", or limits it to what an in network provider's fee would have been.

As with most questions concerning a specific plan, the answer lies in the wording of the plan document - and the administrative procedures derived from it.