Quote:
Originally Posted by oscurodude
If the doctor participates in your plan, and is on the staff of the hospital, the hospital has to participate also so you should file a complaint with your state insurance department on this issue. It's not your fault, but the fault of the hospital
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Not sure where you got this info, but, no, they don't.
I assume we're talking about a private insurance provider.
Insurance reimbursement is based on negotiations with the individual providers. Usually those negotiations go like this:
Here's what we're willing to pay for these services this year. Take it or leave it.
The provider can either accept the payment, or decline. If they say no, they essentially decline any payments from that insurer. Here in Western PA the two biggest health care providers also each own their own health insurance providers. Needless to say, they won't take the other's insurane. So you have to go to the hospital who owns your health insurance provider.
I didn't mean to imply that you should have checked policy on the way to the ER. This is something you should have checked when you were issued the policy. I agree that these policies contain a lot of legalese, but the covered services and in-network providers are usually easy to find.
Again, double check with your insurane carrier. Some policies will provide some reimbursement for out of network providers. It may only be 40-50% of the total bill, and they usually send you a check rather than pay the provider. But it is some relief, and the hospital will usually work with you for any balance.