Delivery - not my doctor - out-of-network for my insurance

Re: Delivery - not my doctor - out-of-network for my insurance

• BeachCouple member

  January 2014

  I would think as long as the hospital you delivered at was in network and that dr was on call for the hospital, it would be covered

  

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• laynal member

  January 2014

  I work for and insurance company, and As long as you are at an in network facility they will pay at the in network benefit level. It's important to keep in mind though that it's not based on billed charges what they are paying. It's based off what the average "going rate" is for the procedure they billed. So basically any amount that goes above that going rate you can be liable for if the dr chooses to bill that to you.

  

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• nycAug2014 member

  January 2014

  laynal said:

  I work for and insurance company, and As long as you are at an in network facility they will pay at the in network benefit level. It's important to keep in mind though that it's not based on billed charges what they are paying. It's based off what the average "going rate" is for the procedure they billed. So basically any amount that goes above that going rate you can be liable for if the dr chooses to bill that to you.

  But your talking out-of-network balance billing, they cant balance bill in-network.  So are you implying if an out-of-network doctor delivers for me I CAN get balance billed? Even if its out of my control who my doctor is the day of? 

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• nycAug2014 member

  January 2014

  AFwifelife said:

  I feel like this is a question you should ask your insurance company about.  Every policy has different rules and regulations and you will get a clearer answer if you just call them.
  

  Trust me, I have asked them 4 different times now and got 4 different answers.  Basically, they said I can fight it after the fact but cant guarantee it will be processed in-network unless its considered an emergency, which not all pregnancies are. But I just cant take that risk.  So I was wondering how it was processed for others when this happened. 

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• cagoldi member

  January 2014

  nycAug2014 said:

  
  

  AFwifelife said:

  
  

  I feel like this is a question you should ask your insurance company about.  Every policy has different rules and regulations and you will get a clearer answer if you just call them.
  

  
  

  Trust me, I have asked them 4 different times now and got 4 different answers.  Basically, they said I can fight it after the fact but cant guarantee it will be processed in-network unless its considered an emergency, which not all pregnancies are. But I just cant take that risk.  So I was wondering how it was processed for others when this happened. 
  
  Well, no pregnancy is ever an emergency, but some deliveries are. Anyway, unless you have an induction or are going for RCS you can't control what doc will be attending your birth.
  
  If they bill you OON for the physician's professional fees you should appeal it.
  
  As far as balance billing, they can do that since they don't have a contract that dictates they will accept the plan's reimbursement rate. However, if this does happen you could call the doctor and request that they accept your insurance as payment in full. You could also ask them to give you a cash price.
  
  They can say no, but it wouldn't hurt to ask. And as I stated before, you can always appeal.

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