insurance, billing and Children's

[Anonymous]

Does anyone have any tips on dealing with insurance and Children's with billing? We've got to several outpatient appointments (genetics, developmental peds, etc) and despite getting someone to run through codes with us, calling insurance to make sure the codes are covered, invariably, insurance gets billed for multiple things and refuses to cover (a generally very expensive) one of them. They always pay the doctor's charge, but all these secondary charges get disallowed (so we don't even get the network rate, we're responsible for full charge). It seems to be a mix of BCBS (who I hate, we have to fight them tooth and nail on everything) and children's awful outpatient billing practices (which are already bad because we get charged our hospital coinsurance %, not our co-pay amount). Some issue with billing from the hospital, clinic fees (which children's insists are facility fees and covered and BCBS insists are clinic fees and not), etc. I can never get a straight answer from either, but I'm particularly ticked that no matter how many times I talk to someone at Children's I never get all the information about everything we're going to be charged for, so even if BCBS could give me a straight answer they'd honor, I wouldn't know to ask (like the clinic/facility/whatever because children's owns the building which is miles upon miles away from the hospital fee). We have enough medical expenses as it is covering therapies and such, and I always verify we're in network and follow the rules and make the calls ahead of time and read the plan book front to back and still, every single time, we get hit with a charge (thus far ranging from $150-600+) that no one disclosed ahead of time that insurance insists they don't cover.

Help?!? Is this standard for Children's, a routine issue? Should we just refuse to ever be referred to someone at Children's again? (a bit of an issue given our pediatrician is CP&A and while they bill differently, they still refer to children's almost exclusively, and then the issue of switching providers who we're supposed to see on an ongoing basis for follow up) We've only had BCBS for a few months, and went to Children's with prior insurance, and these charges never even showed up, let alone got passed on.

[Anonymous]

We go to Children's and see a geneticist and never got hit with a facility fee (I'm still mad about the $500 facility fee we got charged at KKI for a one hour dr appt) and this is with BCBS. Never had the issues you are experiencing either. It's not necessarily BCBS but the particular plan you have with them. I actually have no complaints re billing for the procedures and appts we had there.

[Anonymous]

OP, sorry you are dealing with this. It seems especially frustrating to have to deal with a sick child and these kinds of issues at once.
I had similar billing issues when my child was seen by a physician at Children's a few years ago. Most doctors associated with Children are on salary at the hospital and the visits and services you receive are considered outpatient hospital visits, even when you just have a plain old office visit. That triggers a big facility fee and often has totally different (and much higher) cost sharing than the traditional copay.
That was my experience, even after having called and asked explicitly if the doctor was in-network and I would face my specialist co-pay.
I refused to pay and threatened to report them to the state insurance commissioner for giving me false information. They agreed not to pursue payment but said I couldn't make another appointment at Children's until I paid the bill. I chose to find another specialist.
Unfortunately more and more pediatric specialists are being bought out by Children's, making it harder to find docs, but I have so far managed.
Bottom line is I sympathize, wish I had a great solution. But consumers need to fight back or its just going to keep happening.

[Anonymous]

I had a bitter battle with Childrens and Aetna. Our ped referred us to Childrens for suspected autism. I checked and both the hospital and the doctor were in-network. But the "billing code" they used for the autism screening was not a code my insurance reimbursed for--they used an 'educational testing' code and we went around and around and they flatly refused to change the code. I appealed the insurance denial and was denied. I told Childrens I was NOT going to be paying the $900 or so and I would love to see them in small claims court.

I honestly have no idea what happened to the bill-its not on my credit report. I really hate dealing with Childrens.

[Anonymous]

I have CareFirst and have never faced these issues. However I have noticed signs that say I could be charged. And our health insurance broker warned us about this with hospital based specialists. Apparently it is becoming more and more common. Blah. It's not just Children's alas.

[Anonymous]

I have had terrible experiences with Children's billing. We've basically stopped using Children's altogether.

If Children's is in network for you, I would rely more on the insurance company for info. In the past, I have written letters to Children's saying, "my insurance company says if you bill this service as X, it will be paid. Rebill the service if you want to receive payment." or "My insurance company says that they do not pay facility fees. As an in-network provider, you are bound to accept what the insurance network provides." I've also had Children's try to send my lab work to their own lab instead of to the lab my insurance covers. Again, I wrote a letter describing their error and saying I refused to pay for their internal error.

If Children's is out of network, for you, then you are basically SOL, as they can charge you whatever they want and they are not bound to take your insurance reimbursement as payment in full.

[Anonymous]

Know your medical policy well. When I call insurance to ask if something is covered, I ask them to point to me on the policy where it's stated in writing. Then I save that in the event a claim is denied. And believe me when you see a number of specialists there's a chance something will be misconduct or denied.

[Anonymous]

Miscoded, not misconduct! Dyac

[Anonymous]

Thanks all. They're definitely in network - that's part of what I don't understand. If I go to an in network doctor, for a covered service, and see only that in network doctor, how could I possibly end up with a charge for something that isn't covered? I thought too they were contractually obligated as in network providers to follow whatever insurance allows as far as billing - it's not like they can say, well yes, insurance only allows $90 for an office visit, but we're making you pay the extra $100 we'd like to charge, so how can they say, well, yes, insurance doesn't cover facility fee, so we're charging you the extra $150?

It does suck because there really are almost no non-hospital based specialists for some of these things (there may actually be none). And when we go for one appointment (say genetics) we don't get a facility fee (but did get some parent education fee that wasn't covered or disclosed ahead of time) and when we go for ophthalmology - same building, different floor - we DO get a facility/clinic/whatever fee. How does that make ANY sense!? And what I'm getting from insurance is if Children's would just bill using code XYZ, which is the facility fee code, rather than ABC, which is the clinic code, then it'd be covered, at least partially under outpatient benefits. Nevermind that nowhere in our plan documents that I was provided with does it say these "clinic" fees aren't covered (nor can anyone explain what a clinic fee is...) Sad to hear it's neither unique to us or BCBS and I guess we just have to refuse to be referred to anyone at Children's.

[Anonymous]

Hey OP, sorry I can't help you with your specific problem, but I read this article recently which sounds like a relevant subject to your life.

http://www.slate.com/articles/news_and_politics/politics/2015/03/america_s_hospitals_our_system_lets_big_hospitals_charge_exorbitant_prices.html

Looks like this problem is just going to get worse and worse. I wish you luck.

[Anonymous]

Are you with Anthem or Carefirst? If Carefirst you can look up the policy using their search on the website. Go to the Providers section on the website, then Medical Policy -->Search Now. It'll pull up all references to clinics.