r/HealthInsurance • u/Antique_Ad3823 • Jan 26 '25

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

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.

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u/10MileHike Jan 26 '25

OP stated in their opening post: "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. "

How much more due dilligence do patients have to do these days to simply have a procedure? Not only do they have to do what OP did, but also check the status of any and all employees of the surgery center as well who may be there on the day of their procedure?

FWIW, anesthesiologists where I go rotate, they are brought in from the outside,, and you don't know ahead of time exactly who you're even going to get if your procedure is booked out a few months from now. It's all done on an availability basis.

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u/scarykicks Jan 26 '25

Happened to me with an MRI. Got a call saying they spoke to insurance and it was all in-network and approved. I'd pay X amount and my insurance would take care of the rest.

Ala 3 months later I get the bill for $2,500 to pay since it was not in network. It's insane.

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u/nyan-the-nwah Jan 26 '25

I've had to learn the hard way to call literally every party involved in a procedure - insurance, billing office, and directly to provider.

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u/juztforthelols1 Jan 27 '25

And even then that doesn’t guarantee anything

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u/nyan-the-nwah Jan 27 '25

Yup. More than once I've had to pay OOP for something that should be covered (like preventative care), put up a stink for months to no avail, only to receive a check after they get audited years later. Happened with both United and BCBS

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u/throwaway_mog Jan 29 '25

God I hope these scum reap what they sow.

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u/Know_Justice Jan 26 '25

My past experience with insurance supports this. I negotiated my company’s coverage with a third party administrator. The anesthesiologists in my city did not participate with our PPO plan. The community’s radiologists also owned their own practice and thus, were out-of-network. This prohibited us from negotiating a more reasonable price for their services, too.

Because my company self-funded our health insurance, we had the authority to pay for things like facilities and physicians who were not in our network, and we did. However, that was 20 years ago. No idea if they are still picking up the tab.

The doctor in the instant case was likely being honest. What the office may have failed to do was inform the patient that the surgical center and the anesthesiologist were not covered under the patient’s plan. If this is an employer-sponsored health plan, I think the OP should begin with a call to the company’s Benefits department and go from there.

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u/10MileHike Jan 26 '25 edited Jan 26 '25

Yup. The anesthesiologists and radiologist where I live are all out of separate companies.

We actually have only 1 radiology group in the entire city.

ANyway yes, it's gotten to the point that besides paying high insurance premiums, patients have to do quite a research project in order to find out if EVERY service they will receive is covered.

And keeping in mind, you know how many people have never been patients, don't even realize that in addition to the facilities charges for the surgery center, and the surgeon, that they will recieve separate bills from the anesthesiologist, pathologist, radiologist, or anyone who reads a report for them for a simple colonoscopy???

Normal people who have never had surgery would not even KNOW the many people involved in their procedure, if they had no medical background.

I think this is outrageous, it's like a huge "jump thru hoops" undertaking.

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u/juztforthelols1 Jan 27 '25

Its not an accident, they know what they’re doing, its convenient for their racket for the responsibility to always fall on the patient- the party with the least power, experience, tools and time to fight all of this

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u/Know_Justice Jan 26 '25

I was in SW Michigan at the time. The metro area was at least 130,000 people and there was one radiology and one anesthesiology practice. They were huge practices and did not participate with any insurance plan. We considered trying to negotiate with them. But how do you know what their fees are prior to sitting down with them. You don’t. Thus that idea was quickly removed from the table.

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u/LowerLie1785 Jan 26 '25

After 2021, they would need to provide their rates for service.

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u/Know_Justice Jan 26 '25

Thank you. I’ve been retired since 2015.

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u/juztforthelols1 Jan 27 '25

Right, “would” and “must” -> most providers are either not complying or maliciously comply so bad they might as well be not complying or

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u/tmodo Jan 26 '25 edited Jan 26 '25

Don't rely on any medical professionals to verify their network/insurance coverage. This needs to be vetted with the insurance company directly before the procedure.

Call the insurance company and ask if the facility is covered, then check on each specialist. Note who you spoke with, and get their identifying number and document the call - take notes. This is the way!

Edit: not helpful for OP but I hope others are aware

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u/FineRevolution9264 Jan 26 '25

You rarely know the name of the anesthesiologist or CRNA beforehand, and any one center might have more than one group . It can be literally impossibe. .

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u/divinbuff Jan 26 '25

This! How am I supposed to know better than my doctors billing people whether they’re in network or not? I’ve had my own insurance carrier give me incorrect information-and the doctors office too.

And once I had everything approved with an in network doctor, who was sick the day of my procedure so another doctor did it-who wasn’t in network despite working for the same practice!!! How am I supposed to manage that?

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u/[deleted] Jan 26 '25 edited Jan 26 '25

That's the whole point. The system is designed to make it almost impossible for you to do things correctly. And if you make mistakes it's $$$ for insurance and provider.

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u/udsd007 Jan 26 '25

im possible?

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u/[deleted] Jan 26 '25

Yes!

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u/juztforthelols1 Jan 27 '25

It’s by design, the patient its so easy to ef with, the least tools, experience and time to fight this

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u/Emotional_Wheel_7140 Jan 27 '25

Because the front office at that doctors office gets less info than the actual patient policy holder

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u/MonsieurRuffles Jan 26 '25 edited Jan 26 '25

Doctors rarely have accurate information on insurance coverage. Had a colonoscopy and the center made me make an upfront payment based on their pre-procedure insurance submission. Got the EOB and my OOP was $0 so I got a refund.

The one odd thing is the doctor’s office saying that OP would have a co-pay and everything else was covered. If this was a screening colonoscopy per the ACA, then OP shouldn’t have any costs OOP.

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u/10MileHike Jan 26 '25

Its screening until they find a polyp no matter how small or benign looking. Once snipped it HAS to be sent to pathology. Now you have to know if pathologist is in network.

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u/Actual-Government96 Jan 26 '25

Polyp removal doesn't change it from a screening to a diagnostic procedure. The departments have clarified this: https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/aca_implementation_faqs12

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u/10MileHike Jan 26 '25 edited Jan 26 '25

Thank you. I was just saying that once you have a polyp snipped, then there will be an accompanying PATHOLOGIST who will look at it. they don't just snip stuff and throw in the garbage. Every single piece of tissue removed in a colonoscopy has to go to a Pathologist. So what if pathologist is "out of network"? That is what I was talking about here , in this topic conversation about how to know if "everyone" associated with your procedure is in or out of network.

However, we can talk about the part about sceening versus diagnostic as well. It does confuse me, as I can't imagine anything but the very 1st "recommended for age" colonoscopy being only a screening though. Because once they do find a polyp, that the 2nd time you go you are now in "diagnostic" territory?

Screening colonoscopy:
No gastrointestinal signs or symptoms before the colonoscopy
No polyps or masses are found during the colonoscopy
No family history of polyps or colon cancer
No history of polyps or colon cancer

Diagnostic Colonoscopy:
You may be required to pay a deductible or coinsurance for a diagnostic colonoscopy:
A colonoscopy is considered diagnostic when you’ve had:
Symptoms in the lower gastrointestinal tract noted in your medical record before the procedure, including:
Abdominal pain that doesn’t improve
Anemia
Change in bowel habits
Constipation
Diarrhea
Rectal bleeding
Blood in the stool
Polyps within the past 10 years
A positive stool-based test or CT colonography and require a follow-up colonoscopy

I mean, other than the age at which it is recommended to get your first colonoscopy, I can't imagine most people get one for absolutely no reason? I guess some do, like if nothing was found at all ,no tissue samples were taken that showed anything, and your next "screening" is set for 10 years from now.

THis was actually discussed in the medical topic by a few docs last year, i.e. Insurers will convert a screening colonoscopy that finds polyps to a diagnostic for paying purposes. Its absurd, and I am pretty sure this was done to me the very first time I had a scope. In that case, a doctor must only do the screening. They cannot take any tissue samples w/out bringing the patient back for a 2nd time for a diagnositc /therapeutic colonoscopy. I think I was burned by my insurance company in this way but it was before 2023. ? If pat of your history is family history of polyps, for instance

https://codingintel.com/coding-for-screening-colonoscopy/

I can DM you that discussion.

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u/Actual-Government96 Jan 27 '25

Insurers don't convert a service from screening to diagnostic, they process claims based on how their systems are configured to process the billing codes submitted. Colonoscopies are particularly finicky, there are several different, perfectly legitimate ways to code a screening colonoscopy. Providers need to make sure they are coding based on the insurers' guidance in order to ensure it pays as preventive.

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u/10MileHike Jan 27 '25

Agree with this. It seems a lot of people don't know how to code.

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u/Actual-Government96 Jan 26 '25

They just needed to confirm that the facility was in-network with their insurer.

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u/thecatwasnot Jan 27 '25

I went in for a procedure, met one anesthesiologist and then, 20 minutes later was told the first was called in for an emergency procedure and had a different one for mine. Thankfully all in-network for me but, still. It's insane.

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u/Vladivostokorbust Jan 26 '25

its really insane… the patient is expected to be able to navigate the complexities of insurance and understand it better than the support reps they get when they call. most people do not know that every separate entity involved may or may not be in network regardless of the status of the others.

you’ve got to verify that

  • the specific doctor/surgeon (not the practice) is in network
  • the facility where the procedure is performed is in network
  • all other personnel involved in the procedure is in network
  • all pharmaceuticals involved are included on the formulary
  • all imaging services involved are in network
  • all labs involved are in network

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u/icelandisaverb Jan 26 '25

It's 100% total insanity.

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u/Emotional_Wheel_7140 Jan 27 '25

Literally the people that call for a patients insurance aren’t versed in that individuals plan. It’s much easier for the policyholder that pays that policy to get the information. The front desk person that works at a doctor office that deals with thousands of different insurances are at a more disadvantage as they aren’t the policy holder.

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u/Vladivostokorbust Jan 27 '25

i get that - but no one explains that to the insured. its like we need to start teaching kids in high school how to be insured to be ready for the real world - just like we need to be teaching them basic financial skills.

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u/Emotional_Wheel_7140 Jan 27 '25

The thing is insurance is so profitable because of these issues. And no one blames them. Just the doctors

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u/Vladivostokorbust Jan 27 '25

The physicians themselves ? No. Sometimes staff contributes to the frustration of it all due to incompetence and assuming that patients know and understand complex billing, but the cost of healthcare itself lies largely on Hospitals (especially for-profits such as HCA) and large healthcare groups gobbling up the small practices along with unbridled pricing by big pharma and medical device manufacturers. Also complicit, personal injury/medical malpractice attorneys who exploit overwhelmed patients and their families

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u/PersonalLink7126 Jan 28 '25

It’s the providers more than the insurers. A lot of hospitals and surgical centers are private equity owned. Then the smartest physicians copy their model even in physician owned facilities. It’s intentional to obscure. Easier to perform then demand payment as opposed to disclose and have you shop around.

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u/Emotional_Wheel_7140 Jan 29 '25

Interesting take. I work out of network office. We always says we are out of network. Your insurance says it will cover 80% if allowed fee or etc. but we have no idea what an allowed fee from insurance is and we cannot find out. The insurance intentionally does this .

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u/Emotional_Wheel_7140 Jan 27 '25

They most def should. I always tell my patients in dentistry that we can’t really gather the facts for them. We can try but it’s always best they call. The only people denying payment is that insurance. So hold them accountable. Spend time getting facts and evidence. On the doctor end we will get info that so much is covered and etc. then it’s Denied . And the two people working front desk with a thousand other tasks can’t spend 1-2 hours on the phone for one patient.

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u/Illustrious-Chip-245 Jan 27 '25

Right but did OP call the surgical center and ask if they are in-network? Did they inquire about the anesthesiologists? I’ve don’t both for procedures just to make sure. It’s not the doctor’s responsibility to know about anything beyond their practice.

Its all still a bunch of horseshit that this is the world we live in, but doing your part will make it easier in the long run

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u/10MileHike Jan 27 '25

did you reven read the OPs post? Apparently not.

" 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."

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u/scifibookluvr Jan 27 '25

It’s the anesthesiologist part that is utter BS. No way to predict. No way to get anyone to commit who will provide services in advance. Reading through this thread it seems some plans protect their members by saying if facility is in-network, all services provided will be in -network. Other plans don’t. Does consumer have Any way to authorize only “in network” anesthesiologists are approved? Especially for planned procedures?

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u/Love_FurBabies Jan 26 '25

Always confirm with insurance first. All carriers have online prover directories. You can see if the surgery center and anesthesia are in the network. Also, check your summary of benefits to make sure a surgery or treatment is covered. It is the members' responsibility to verify these things.

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u/[deleted] Jan 26 '25

Be careful with the online directories. They are often not up to date and the insurance doesn't feel bound by them.

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u/Honju Jan 26 '25

100% This. I spent several phone calls arguing this with bcbs because their portal said my provider and facility were in network but my EOB said they were out of network. 

I literally had multiple reps on the phone with me use the portal and go “huh. They are in network” tell me they’d submit it for review, then the review was denied. I finally got it covered after 4 attempts at this

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u/Comfortable_Two6272 Jan 27 '25

I had screen shots and filed complaint with state insurance commission. Ins then paid as in network.

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u/10MileHike Jan 26 '25

"it is the member's responsibillty to verify these things"

As I noted in my above post, patients have NO IDEA just how many "providers" might be involved in a procedure or surgery. How do you suggest they just automatically know these things?

I expect to just be able to ask at my surgery center. Will there be an ekg before the surgery, is the radiologist iin charge of reading any and all reports in network? HOw about the anesthesiologists you use? What about any and all other ancillary services? Pathology, etc.

How was I to know when i got my cataracts removed that the surgeon was going to use a very specicalized medication DURING my surgery that my insurance didn't pay for? How would I even know that unless I had a background in opthamology?

I knew the drops that were prescribed before and after the procedure were specialized for the surgeon, made by a COMPOUNDING PHARMACY, so I knew my Part D would not pay for it.

But how would a patient know that something that happened during a surgery something else had to be used? Are you expected to wake up on the operating table and call your insurer to ask ?

This meme of "it's the members responsibility" sounds so much like what an insurance company employee would say.......and isn't helpful in about 80% of every single procedure I have had.

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u/FineRevolution9264 Jan 26 '25

I'm exhausted by all the insurance apologetics on this sub. They disgust me.

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u/10MileHike Jan 26 '25 edited Jan 26 '25

Its okay. Everyone knows who the "plants" and "shills" are here. We look at their histories.

There are a few who are actually helpful.... and are not bashing patients. The ones that bash patients you definitely want to block. I do.

What I go by is what doctors (real ones) share about how insurance companies deal with things.

ITs also one of the reasons many doctors in the U.S. are leaving practice and going into research or other work..

Its not like the abusiveness of SOME insurance companies is a big secret at this point. I think the best thing is to educate yourself but that's hard to do with some of the schills who keep finger pointing at you. Just ignore them.

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u/Naive_Location5611 Jan 27 '25

My kids’ insurance company has providers listed who went out of business two to three YEARS ago.

All of the specialty providers for two specialities I needed were listed as accepting pediatric patients and none  of them actually saw pediatric patients. 

They also told me that they update the list monthly but they are aware the list is inaccurate. 

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u/LowPost5494 Jan 26 '25

The doctor and billing office. Not their insurance co. Always, always, go online and use their cost estimator or call to ask for one. The insurance co holds the strings on who gets paid what, not the Dr.