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Specialist Visit vs Outpatient Facility Charge

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Old 07-13-2012, 07:22 AM   #1
Join Date: Jul 2012
Location: Maryland
Posts: 1
mn123 HB User
Specialist Visit vs Outpatient Facility Charge

My insurance has specialist visit copay as $35 and have $1000 deductible for any outpatient treatment.

My son was seen by a speech pathologist 4 years ago by a doctor at John Hopkins (different insurance at that time) and was covered as specialist visit. We just wanted to make a follow up visit to same doctor, just to make sure that there is nothing need to be done further and my son has overcome his speech issue (which he did).

Before going to this same speech doctor, (who is available only at John Hopkis Hospital) we called our new insurance company and asked if the doctor is in our N/W and what will be my Out of Pocket expense. The Insurance confirmed that the doctor was in the network and our OOP will be $35 copay.

We visited the doctor and there was no treatment, test or admission. It was just an office visit, she talked to my son and said everything is fine.

Now when we got the bill for $350, we were denied payment by insurance. When we called insurance we were told that the bill was coded as "Outpatient Facility Charge" so the deductible will apply. We told that it was a specialist office visit and we were told that $35 copay would apply, the insurance told us to call hospital and let them file under "correct" code and they will process the claim.

When we called hospital they said that is how they bill even for specialist visit. When we referred to the 4 years ago consultation, they said that last year they changed the billing practice and that's how they do it, and they cannot rebill. We asked hospital for itemized bill.

Now when we got itemized bill, there is only one line item - speech evaluation. Nothing else. When we called back hospital and asked why speech evaluation is being billed under "facility charge"? There answer was this is how they do it and we have to take this matter to our insurance.
When we called insurance they says, hospital need to rebill and they can process only with the code hospital is provided.

Hospital is threatening us to send the bill to collection, but if they just rebill under correct code, insurnace will pay. Something which should have cost $35 is now costing us $350 even though we verified from insurance before going to the specialist. How are we suppose to know that hospital changed their billing practice and doctor visit will be billed as outpatient facility charge?
Anything we can do? Any help?

Last edited by mn123; 07-13-2012 at 07:25 AM.

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