MAPD out of network radiologist question

[Limozine]

I have a MAPD member with UHC who is going in for an MRI in a couple of weeks. The (big) hospital system in our area is in-network, and his MRI network co-pay is $90, so it should be cut and dried (IMO).

However, this week he receives a letter from the hospital telling him how many thousands of dollars the MRI normally costs and that his responsibility is $90. So far so good. But then the letter goes on to tell him that "Your visit includes care from providers who will send a separate bill...etc." under the heading "External provider fees." The total for these "fees" is $397. When he calls to enquire about this, he is told that it depends on which radiologist comes in to "read" the MRI. Apparently the hospital system uses some radiologists who are in-network and some who are not.

The whole thing seems kind of scammy to me. My advice to him was to simply insist on an in-network radiologist. Any thoughts or suggestions?

 

[billyb]

Getting an MRI for a $90 copay is a bargain. Anytime he has imaging done a specialist will have to read it thus an additional charge. Have him request an in network provider. He can call UHC or ask his agent for a name. If he had bought a Medicare Supplement he wouldn't be having any issues.

 

[Chazm]

I’d tell him to go somewhere else.

 

[somarco]

Apparently the hospital system uses some radiologists who are in-network and some who are not.

Many hospitals, including large ones, have specialists and even nursing staff that are not hospital employees, but rather, contract employees.

Much of the ER staff consists of contract employees. Same for radiology, lab, anesthesiology, etc.

This is why patients often encounter hidden providers when they have a hospital admission.

Changing to a par hospital may or may not help, depending on how many contract workers they have, and where they work.

OTOH I have been told before (on this forum) that non-par providers you may encounter in a par hospital are paid by the HOSPITAL and not allowed to BALANCE BILL the patient.

 

[LostDollar]

Much of the ER staff consists of contract employees. Same for radiology, lab, anesthesiology, etc.

This is why patients often encounter hidden providers when they have a hospital admission.

Yes.

Happened on:

Surgery with employer health coverage several years ago.

Medicare-ER visit for chest pain.

Medicare-Hip replacement.

All kinds of medical providers doing separate billing.

The whole thing seems kind of scammy to me.

It may be scammy, but I think you will find it is a normal practice in the provision of medical services.

In-Out of network, harder to deal with, harder to control. Don't know how you manage that concern with MAPD.

 

[Midlevel]

My experience with hospital stays for my clients on MA plans has been whatever the daily hospital copay is that is what they get billed. Copay is 350.00/day days 1-5 then they get a bill for 1750.00. If they are in there 2 days then 700.00, etc. Guy had quadruple bypass surgery and wanted to know what he could expect for a bill. I said 1750.00 and that’s exactly what he got. Then of course he got reimbursed 1500.00 from GTL so the entire 150000.00 procedure cost him 250.00.

 

[LostDollar]

[QUOTE="Midlevel, post: 1448129, member: 30494" Then of course he got reimbursed 1500.00 from GTL so the entire 150000.00 procedure cost him 250.00.[/QUOTE]
plus the gtl premiums.

 

[Midlevel]

[QUOTE="Midlevel, post: 1448129, member: 30494" Then of course he got reimbursed 1500.00 from GTL so the entire 150000.00 procedure cost him 250.00.

plus the gtl premiums.[/QUOTE]

Caveat, an agent:

Whopping 30.64/month. Come up with something better then that.

 

[somarco]

Some agents will read this post and will not understand it. At least one agent already has done so and dismissed it as "does not apply to my clients".

Ignorance is bliss . . .

Out of network billing is not the same as balance billing.

A non-par provider is allowed to bill the patient for their services. In some cases the patient is only responsible for the contractual copay or deductible and the provider is not allowed to collect more than the plan copay or deductible.

Balance billing describes a situation where the provider is allowed to bill the patient for an amount that EXCEEDS the payment tendered by the insurance carrier.

If the patient is told they are not responsible for paying bills from non-par providers that patient is given incorrect information.

If an agent tells a client they are not responsible for paying the contractual copay or deductible from a non-par provider that agent may be liable for paying the claim.



Sometimes, where you get health care—or who provides it—is out of your control. Like when you need emergency care or when an out-of-network provider is involved in your care without your choice. When this happens, the federal No Surprises Act or state surprise billing law may protect you from paying more than your copayment, coinsurance or deductible.

Other times, you might choose an out-of-network provider. If you choose an out-of-network provider, the protections of the No Surprises Act or state surprise billing law won’t apply. But your healthcare benefit plan may still cover part of the cost, depending on your plan’s terms.

When an out-of-network provider is involved in your care without your choice, the No Surprises Act may apply and protect you from certain out-of-pocket costs.

The No Surprises Act applies when you receive the following services:

Out-of-network emergency services, including air ambulance (but not ground ambulance)
Out-of-network nonemergency ancillary services provided at a network facility
Nonemergency nonancillary services provided by an out-of-network provider at a network facility if the out-of-network provider did not get your prior consent as the No Surprises Act requires.
For the above services, your copayment, coinsurance, or deductible must:

Be the same as it would have been if the service was provided in your plan’s network
Be based on what your plan would pay a network provider
Count toward your network deductible
Count toward your out-of-pocket limit
[EXTERNAL LINK] - Legal - Payment of out-of-network benefits


When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
[EXTERNAL LINK] - Application Error

 

[somarco]

My experience with hospital stays for my clients on MA plans has been whatever the daily hospital copay is that is what they get billed. Copay is 350.00/day days 1-5 then they get a bill for 1750.00. If they are in there 2 days then 700.00, etc.

There are 4 situations where I can see that happening and the patient is not billed for anything other than the hospital inpatient charges.

The surgeon, assistant surgeon, anesthesiologist, etc. were all on staff at the hospital and are paid by the hospital as regular employees.

The surgeon, assistant surgeon, anesthesiologist, etc. failed to bill the patient for their services . . . or they decided to work for no charge.

The patient is clueless.

The agent is clueless. Also, an agent that gives the client a definitive "this is all you will pay" statement, should anticipate an E&O claim to occur.

Note . . . services incurred while in the hospital and billed by the hospital are covered by Medicare Part A . . . regardless of whether the patient has original Medicare or an MAPD. If the patient has original Medicare, the patient is responsible for the Part A deductible ($1600 per admission in 2023), but may not have to pay it if they have a Medigap G plan. If they have an MAPD plan, they are liable for the daily copay up to the plan limits.

Charges for services incurred while in the hospital but not billed by the hospital, fall under Medicare Part B. If the patient has original Medicare, the patient is responsible for the Part B deductible ($226 per calendar year in 2023), but may not have to pay it if they have a Medigap G plan, and they have satisfied their Part B deductible for the year. If they have an MAPD plan, they are liable for copays and deductibles up to the plan limits.