In network Specialist Dr sent biopsy material to innetwork path who then sent it to out of network

[Anonymous]

Has anyone had anything similar happen. Now we have a whopping $500 out of network bill. We did not know it was being sent for a 2nd opinion, much less out of network.

We are really underwater with extreme medical costs. Is there anything we can do? Our insurance company told us to take a long walk off a short pier.

Thank you for constructive ideas!

[Anonymous]

Contact your state insurance commissioner. They can help you understand your rights and push back on your insurance company.

[Anonymous]

Something similar happened to me at a Children's Hospital Doctor's office. Children's does lab work themselves or their website sends it out to Labcorp. Our insurance only pays for lab work at LabCorp. Children's sent the specimens they collected for in house analysis and sent us a bill for $2000.

I called Children's and pointed out that they had my insurance card and I had not consented to sending the Lab work out of network and that their website said they used my insured lab. I did not have to pay the bill.

I have also had something similar happen at Georgetown, when an unauthorized out of network doctor took part in an anesthetized procedure my child had. The doctor also participated without my consent, and I did not have to pay his bill.

Consent is key. You had the sample taken by an in network provider, that provider sent it to an in network provider and that provider sent it to someone else not in network. Did you sign paperwork providing blanket consent? If not, you may have no recourse. This is why I never sign blanket consent. If I am given a consent form, I modify it to make it clear that I am consenting to treatment only by the in network physician with whom I have an appointment or other in network providers.

I don't think you'll get anywhere with the insurance company. It isn't their fault that the provider didn't send the sample to the right place. I would submit the out of network bill and see what your insurer pays for it. Sometimes the insurer will pay at the "in network" percent reimbursement while still basing the percent reimbursement on the insurer's UCR, if you can demonstrate that this provider that was used provides a necessary service that is not provided by in network providers. For example, my DC needed treatment by a concussion expert. He was out of network. Let's say he charged $1000. The UCR was $200. The out of network reimbursement was 50%, but the in network reimbursement was 80%. Now I will get $160 back instead of $100, but since the provider was out of network, I am still stuck for the balance of 1000-180.

Once you get the reimbursement, I would forward the reimbursement plus any copay you would be expected to provide to the provider and say that you expect them to accept the amount offered by the insurer and your copay as payment in full since they sent the sample to an out of network provider without your consent. Make sure you say that the sample was sent "without your consent."