Advocacy in Action | Assistance with Anesthesia Bill
A member’s daughter had a history of seizures and her pediatric neurologist recommended an MRI be completed. Due to the child’s young age, sedation was required to perform the testing. The MRI testing was arranged and scheduled at an In-Network hospital. The testing was performed by In-Network service providers except for the anesthesia. The anesthesiologist performing the sedation was an Out-of-Network service provider and he charged the member the Out-of-Network rate. After the claims were processed by the insurance carrier, the member received a $3,478.00 bill from the anesthesia service provider. The member was shocked and contacted Purple Card for help. The Patient Advocate reviewed the claim and found the actual charge for the anesthesia was $3,601.00. The insurance carrier processed the claim at the higher In-Network payment rate and sent a payment to the service provider for $123.10. They also let the service provider know the patient responsibility was an additional $151.93 deductible and $30.77 co-insurance, or a total of $182.70. When the service provider received the insurance payment, they balance billed the member for the unpaid difference between the actual change and the payment received from the insurance carrier, $3,478.00. After reviewing the billed charges and the claims payment and amount, the Patient Advocate reached out to the service provider and asked them to accept the insurance carrier’s In-Network processing of the claim and also asked them to accept the member’s additional payment $182.70 as full and final payment for the services. The service provider refused. The Patient Advocate then worked with the member to submit the anesthesia bill for review to the Texas Department of Insurance Mediation Program. The mediation program allows insureds with coverage through a preferred provider organization plan to submit an Out-of-Network hospital-based physician charge bill, which in this case was an anesthesiologist bill, if the amount owed by the insured is more than $500. The mediation process can take up to 180 days and the Patient Advocate monitored the progress during the mediation period. The mediation was successful, and the service provider settled the matter for the additional payment of $183.00. With the help of Purple Card, the member saved $3,295.
At Brinson Benefits, we care about the patient’s best interest. We believe the patient should have an available healthcare navigator and advocate. Our Patient Advocates at The Purple Card® are highly trained to educate members about available benefit programs. They work hard to resolve issues with providers and insurers.
The Purple Card® is an independent health care advocacy and assistance service. Our Patient Advocates provide time and cost-saving services to resolve concerns about benefit programs. We not only assist our members, we educate them on ways to maximize health care coverage and other available benefit programs.
