My daughter this week received a bill for $1200 (!!!) for cardiac event monitoring she had 23 months ago! Her regular cardiologist (an "in-network" provider) ordered the test for an irregular heartbeat. BC/BS of AL routinely pays costs associated with her visits and tests, with this cardiologist - never a problem.

With this kind of monitor, when you notice a funny heartbeat, you record it, and periodically call in to the monitoring center, transmitting the data over phone lines; this particular company is in Georgia. When we checked the claim on the BC/BS site, it indicated that they classified it as an "out of network" provider, subject to a $400 annual deductible. Though the bill was for $1200, the "usual charge" was $368, not exceeding the deductible, so, according to them, we are iable for the whole $1200.

BC/BS online customer service has been a brick wall; this will require an in-person visit. I am wondering about the "out of network" thing (not to mention the fact that it took the provider nearly 2 years to send us a bill, though BC/BS apparently processed the bill in June '06.)

Do we have a leg to stand on? What should we do next? I am upset at the "out of network" classification, though this was all done through our local physician and the only contact we had with the event monitoring company was over the phone.

Thanks for any input.

Hi Dixieagle!

This may or may not work; good luck. :)

Find out if the monitoring company was truely out of network at the time of service. If they were out of network, there may not be much you can do. The cardiologist's office should be able to help you with this; depending on how well staffed they are.

If they were in network at the time of service, call BCBS and ask to have the claim reprocessed; also, call the company and ask them to have it reprocessed.

The company may have been fighting with BCBS to get this paid, and that may be why it took so long for them to send you the bill. Sometimes, companies will bill the patient only as a last resort. Believe it or not, insurance companies are a lot nicer to the patients than they are to the doctor's offices. :)

Finally, if all else fails, carefully read your EOB. It should state exactly what you owe.

Hope this helps!

Good Luck!

Any PPO contract specifically states they are supposed to get direct a patient's care to another PPO provider. Many of them do.

Ones like this, however, purposely contract with a non-PPO provider to supply the monitor and never tell you, the patient, that they are out of network. Then you end up stuck with benefits being applied to your out of network deductible co-pay.

Why is this done by YOUR in-network doctor? Theories abound. One of them of course is that out of network reimbursement rates are generally higher than the PPO contracted ones...and the monitor place might be giving your doctor a cut of the reimbursement they're getting.

Bottom line is A) it's your responsibility outside of an emergency or in-patient situation to verify that all your providers are in-network and B) your physician's office should be making you aware of the fact that the place they exclusively use isn't in-network. It's called informed consent and maybe they did--it may have been one of those forms so many people just sign without reading.

Doctors and hospitals pull this with pathologists, anesthesiologists, radiologists, etc., pretending that they just can't coordinate your care with another in-network physician--despite the contracts they sign with the PPOs stating they should--and then try to pin the blame on the insurance companies.

Take it as a buyer beware situation. Next time you see him, tell him how angry you are and that next time he orders something, to verify that all parties are in-network or ask for the names so you can verify it yourself. If he refuses to do that...take your business somewhere else.