Re: out of network but paid as in network

[Guest guest]

we did but dhs work is self insured so we went straight to the healthcare administration company, bypassing the insurance company that our claims are usually filed trhough before we got his band

On Tue, Jun 29, 2010 at 11:31 AM, <sosweet_jme@...> wrote:

 

Has anyone out there got their insurance to pay for the band as " in network " although the treatment was done by an " out of network " provider? A woman at my insurance company said that it's unlikely that they will pay my claim as " in network " unless I can prove that the Doc Band is superior to the other helmets out there. Can anyone provide me with any tips or documents that will help?

-- -mommy to Emma, Becca, , , , and baby girl no name (yeah I know, nothing new, does ever pick a name in a timely manner?) July 2010

[Guest guest]

In my experience - and hopefully someone will have a better experience than I did - I was not able to get an in-network price. I was able to get something called a 'Gap Extension' or 'in for out' applied to my claim to apply my in-network deductible (already met for 2010) vs. starting over with my out-of-network deductible ($1500). However, the fee reimbursed for the helmet was still what the insurance deemed the out-of-network 'reasonable and customary' fee which was $700 for CT helmet. I believe the provider and insurance company have to have a contract for in-network reimbursement to apply because they have an agreed upon fee. To me, CT & my insurance company couldn't agree upon a fee so they couldn't get a contract signed and therefore we are out-of-network. Depending on the insurance company, I know people have been able

to fight and win to cover the whole thing. It's alot of work with the insurance so good luck!! Two things I've been told - use e-mail communication for a 'paper trail' with insurance companies and keep asking questions from different people - if you don't like what you are told, e-mail again and ask someone else. I found a Star Cranial Center of Excellence that was in-network so luckily we are able to do that. I felt strongly that I only wanted to go to a place that worked with helmets and no other devices. From: <sosweet_jme@...>Subject: out of network but paid as in networkPlagiocephaly Date: Tuesday, June 29, 2010, 10:31 AM

Has anyone out there got their insurance to pay for the band as "in network" although the treatment was done by an "out of network" provider? A woman at my insurance company said that it's unlikely that they will pay my claim as "in network" unless I can prove that the Doc Band is superior to the other helmets out there. Can anyone provide me with any tips or documents that will help?

[Guest guest]

the one con I found to CT was they wouldnt even discuss it with the healthcare administration company to get a contract signed.

On Tue, Jun 29, 2010 at 2:09 PM, Crane <heathersmith310@...> wrote:

 

In my experience - and hopefully someone will have a better experience than I did - I was not able to get an in-network price.  I was able to get something called a 'Gap Extension' or 'in for out' applied to my claim to apply my in-network deductible (already met for 2010) vs. starting over with my out-of-network deductible ($1500).  However, the fee reimbursed for the helmet was still what the insurance deemed the out-of-network 'reasonable and customary' fee which was $700 for CT helmet.  I believe the provider and insurance company have to have a contract for in-network reimbursement to apply because they have an agreed upon fee.  To me, CT & my insurance company couldn't agree upon a fee so they couldn't get a contract signed and therefore we are out-of-network.  Depending on the insurance company, I know people have been able to fight and win to cover the whole thing.  It's alot of work with the insurance so good luck!!  Two things I've been told - use e-mail communication for a 'paper trail' with insurance companies and keep asking questions from different people - if you don't like what you are told, e-mail again and ask someone else. I found a Star Cranial Center of Excellence that was in-network so luckily we are able to do that.  I felt strongly that I only wanted to go to a place that worked with helmets and no other devices. 

From: <sosweet_jme@...>Subject: out of network but paid as in network

Plagiocephaly Date: Tuesday, June 29, 2010, 10:31 AM

 

Has anyone out there got their insurance to pay for the band as " in network " although the treatment was done by an " out of network " provider? A woman at my insurance company said that it's unlikely that they will pay my claim as " in network " unless I can prove that the Doc Band is superior to the other helmets out there. Can anyone provide me with any tips or documents that will help?

-- -mommy to Emma, Becca, , , , and baby girl no name (yeah I know, nothing new, does ever pick a name in a timely manner?) July 2010