Have contingency if health facility is pending as 'in-network' - FOX5 Vegas - KVVU

CBS 5 Advocate

Have contingency if healthcare facility is pending as 'in-network'

Posted: Updated:
TEMPE, AZ (CBS5) -

A Tempe man ended up with a huge unexpected healthcare bill due to a provider mistake that can arise when medical facilities try to get approved by insurance companies.

Most times it is crystal clear, either the facility is 'in-network' with your health insurer or it isn't. But sometimes an in-network approval is in process. In that case, you need to have a specific discussion with the billing department prior to your procedure.

David Doyle's pancreatic condition requires him to take special enzymes when he eats. He also gets a screening every year at Arizona Digestive Health. Last year he learned Arizona Digestive Health would be performing the procedure at a new surgical facility owned by some of their physicians. Doyle learned this new facility, called Arizona Advanced Endoscopy, was not yet in-network with his insurance.

"We've done all of our paperwork, the application is in process, we will be in-network by the date of your procedure," Doyle said.

Doyle says ten months after the procedure, he received notice from his insurer that he owed more than $1500 to Arizona Advanced Endoscopy. Doyle says he knew that couldn't be right. He knew that under his plan, facility charges were covered 100% if in-network. That is when he noticed Arizona Advanced Endoscopy had submitted the claim as out-of-network.

"I asked them why it was billed as out-of-network and they told me they didn't have their in-network status until three months after my procedure," Doyle said.

Since he never got any updates from Arizona Advanced Endoscopy regarding their status, Doyle assumed they were approved as in-network. He felt Arizona Advanced Endoscopy should accept what his insurer paid on the out-of-network claim and write off the difference.

"I don't owe this money, clearly there's a mistake that's been made, I didn't make it, please fix it, and they refused to fix it," Doyle said.

Doyle's learned if any provider says their in-network status will be approved prior to a procedure, agree on a contingency plan in case it isn't.

"I'll ask them to bill it as out-of-network and accept the payment or reschedule it at a different facility that is in-network for me," Doyle said.

Bottom line: Make the practice agree beforehand to accept the amount you would owe an in-network provider or insist they schedule you somewhere else that is in-network.

Arizona Digestive Health says they were not aware of the billing dispute because Arizona Advanced Endoscopy is a separate company.

Once CBS 5 News brought the dispute to their attention, Arizona Digestive Health apologized for the scheduling error and wrote off Doyle's entire balance owed to Arizona Advanced Endoscopy to zero.

CBS 5 News wishes to thank Arizona Digestive Health for their quick and decisive action in remedying this problem.

Here is a statement from Ian Rogers, spokesperson for both Arizona Digestive Health and Arizona Advanced Endoscopy:

"We can assure Mr. Doyle the balance has been written-off in full. Mr. Doyle currently has a zero balance with both AAE and ADH. Additionally, I have personally spoken to Mr. Doyle to apologize and to verify for him his account has been settled. Arizona Digestive Health is passionately committed to providing an outstanding level of care and support for our patients and expects that commitment to be shared by those organizations we partner with. We appreciate your efforts to bring this to our attention so that we could resolve the issue for Mr. Doyle."

Copyright 2014 CBS 5 (KPHO Broadcasting Corporation). All rights reserved.

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