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Keywords: Insurance, appeal, out-of-network, in-network, health care insurance.
Citation: McLaughlin SM. Out-of-network provider billed as in-network: my appeal process. J Participat Med. 2016 Nov 16; 8:e16.
Published: November 16, 2016.
Competing Interests: The author has declared that no competing interests exist.

The idea for this article began when I received an email from a fellow member of the Society for Participatory Medicine titled “out-of-network nightmares.” In it he asked if anyone had had issues with receiving coverage due to seeing an out-of-network provider. At the time I received his email, I was in the middle of fighting an out-of-network coverage denial myself and figured I might share my story hoping to help even one person who might face a similar problem.

I have been diagnosed with generalized anxiety disorder, panic disorder, and insomnia since I was about 10 years old. I am now 22 years old. During the 10 or so years that I have been coping with these conditions, I have been treated using both drugs and cognitive behavioral therapy. For the past few years, I have relied solely on medications to treat my symptoms because they work better than anything else I have tried.

But on August 2, 2016, I presented to North Shore Medical Center (NSMC) in Salem, Massachusetts, with complaints of increasingly frequent panic and anxiety attacks and an overall increase in my generalized anxiety which began a few weeks previously. After being evaluated by NSMC’s psychiatric triage department and a physician in the emergency department, I was admitted for further evaluation and for adjustments to my medications. After spending one night at NSMC, I was transferred to Baldpate Psychiatric Hospital (BPH) in Georgetown, Massachusetts, where I was treated for 3 days.

Before my transfer, a caseworker at NSMC called to confirm with Aetna, my insurance provider, that my treatment at BPH would be covered. Sure enough, BPH is an in-network facility under my health insurance plan and would cost me nothing out-of-pocket. Or so I thought.

Because I was to receive inpatient care at an in-network hospital, I should have had no charges applied toward my zero-deductible insurance plan, nor any copayments billed to me. What I did not know was that my attending physician at BPH was not an in-network provider and his claims were submitted to Aetna separately from those of the hospital.

About a week after my discharge, I logged online to my Aetna account and saw four claims from BPH: one for my hospital stay, and one for each of the 3 days that my physician visited and treated me. The claim for the hospital, which totaled a few thousand dollars, was covered in full and I was not financially responsible for any part of it. The three claims for the physician’s services were all rejected by Aetna as he was not an in-network provider under my plan. I was, until this point, unaware of this fact.

I immediately called Aetna’s customer service department to see what could be done about these claims. I was receiving inpatient care at an in-network hospital and I felt that I should not be charged for any services I received while there. After being placed on hold for some time, I was told by the representative that she could do nothing, but that I could file a separate appeal for each of the three claims in question. Later that day, I did exactly that.

In my appeals, I stated that I was not given an option to select an attending physician who is in-network and covered by my insurance plan, that the hospital itself was in-network, and that because I was receiving inpatient care, according to my plan and benefits, I should pay absolutely nothing for my stay and treatment at BPH. I concluded my appeal by stating, “Because I was admitted to an inpatient facility which was in-network, and because these were inpatient services, and because I had no control over which physician would be assigned to my case, I move that this claim be reprocessed and that this provider be considered an in-network provider for the purposes of this claim.”

Within a few days I received a letter in the mail from Aetna stating that they had received my appeals via fax, would review them and mail me a letter within 2 weeks regarding their approval or denial.

Just a few days after that, I received another letter from Aetna stating that all three appeals had been approved and reprocessed. To verify, I logged online to my Aetna account and confirmed that all four claims from BPH had “$0.00” listed under the column titled “you pay:”

It can be amazing to see how being empowered can save you so much. In my case, my empowerment saved me a few thousand dollars in medical expenses. What strikes me as most astonishing is that I had no control over any of this. The physician was chosen for me and I was expected to foot the bill when Aetna rejected the claim. I wonder how many patients find themselves in similar situations. How many of them just pay up when they receive a bill? How many realize what coverage and benefits are available to them through their insurance plans? And how many have the know-how and the willpower to stand up and challenge something that is unjust? In sharing my story, I hope to help at least one patient who is in a similar situation. And I invite anyone struggling with a similar problem to reach out to me if you need any help at all, as I know firsthand how frustrating a situation like this can be.

Copyright: © 2016 Sean Michael McLaughlin. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.