$20K colonoscopy, when dr’s billing office said $50 in email?

[u/Antique_Ad3823]

Had a colonoscopy by an in-network doctor, at their own surgery center. Before the procedure I spoke with the doctor and billing office to make sure it was all in-network. They confirmed in writing via email, explicitly said I’d only be responsible for my $50 co-pay, with no out-of-network charges.

Weeks after I get 2 denial EOB letters from my insurance, saying the surgery center and anesthesiologist are out of network, and I’ll owe $20K. After some googling it looks like the surgery center and anesthesiologist aren’t in-network with any insurance!

What is happening? Will the doctor’s office really come after me for $20K, when in writing they said I’d only be billed for $50? If so, what can I do? I’m not sure if No Surprises Act will cover this.

[u/Mountain-Arm6558951]

Yeah I would call up and talk to the office manager, something does not seem right if they are not in network at all with any carrier and if the doc did not do a pre auth at all.

Some fishy business practices....

If you are on a HMO, you may want to file a complaint with the carrier as they should not have a provider in network that is using out of network facilities. In some states for HMOs the provider by law must have privileges at a in network facility. If your plan is not self funded you may want to file a complaint with the department of insurance.

[u/Antique_Ad3823 → u/Mountain-Arm6558951]

Complaints are fine, but if the doctors office tells you in writing they won’t bill you for out-of-network expenses, and then bills you $20K, shouldn’t you be able to sue them? If so, any idea the type of attorney for this type of issue, like personal injury or medical malpractice?

[u/xylite01 → u/Antique_Ad3823]

I'm not a lawyer, but I'm fairly certain that if you don't actually pay the 20k, there's nothing to recoup. A lawsuit would probably just end in you not paying anything. Except whatever a lawyer charges you.

That said, administrative and billing mistakes happen all the time. You really should just try to work it out with them first.

[u/krankheit1981 → u/Antique_Ad3823]

I see people advocating for suing all the time but I don’t think anyone realizes how pointless this is.

One, no attorney is going to take this work because the amount they would collect is peanuts.

Two, I’ve defended facilities where people have taken us to small claims court to dispute a bill and all the judge asks is, “Was the billing correct and the patient balance correct?” I said yes, we did everything appropriately and the judge decides in our favor and you still owe the balance. All you did was waste your time, my time and the courts time.

Three, you can’t be credit reported in the US now for medical debt so unless you’ve been harmed by the collection practices (which 99.9% of the time you haven’t), you have no case and it would just get thrown out. Hell, I’ve had people contact the AG and then they start an inquiry and because we don’t credit report, as soon as I inform them of that, they toss it and close the case

[u/justfollowyoureyes → u/Antique_Ad3823]

No Surprises Act has you covered here and it’s especially useful that you have everything, including quoted cost, in writing.

[u/samnewara → u/justfollowyoureyes]

This %100

[u/1Beachy1 → u/justfollowyoureyes]

It does not cover if you intentionally use out of network facilities. Only that the facility must provide good faith estimates of cost.

[u/justfollowyoureyes → u/1Beachy1]

OP has it in writing from their office that it was in-network with no out-of-network costs, just a $50 copay. Now if the Dr. office intentionally lied and went through with the procedure, this becomes criminal on their part. I have a feeling the bill will magically disappear when the issue is pressed and the receipts are shown…

[u/1Beachy1 → u/justfollowyoureyes]

Unless the doctors office owns the ambulatory surgical center they can’t make that determination.

The OP was told by insurance it is likely out of network and requires pre-authorization. The written emails was because office staff claimed that it’s not true they need prior authorization, so the OP asked for the office staff statement via email.

The truth will be in the plan documents. The office staff can’t state for certainty that the surgical center is in network unless they are employees of the surgical center and know this with 100% certainty. It’s possible the ASC is only in network with some of the insurance company plans but not all.

For an HMO, it is common for a diagnostic procedure to need pre-authorization. The office staff to claim they know more about the insurance plan without verifying with the plan is concerning. The doctors office staff’s arrogance or ignorance of insurance won’t be a valid tool. Assuming intentional lying is a stretch.

Did the staff who put this in writing work for the GI physician or the actual surgical center?

One staff making an inaccurate claim in writing is not likely to make the bill disappear. However it remains insane to bill $20,000 for a colonoscopy that even a diagnostic colonoscopy with biopsies in a high CoL like CA in a hospital averages only $5000. Why is the cost 4x the high end of nationwide costs?

[u/dehydratedsilica → u/Antique_Ad3823]

You might find this podcast interesting: https://armandalegshow.com/episode/former-bad-guy-lawyer/