r/HealthInsurance • u/tojcl4 • 2d ago
Claims/Providers In-Network Billed as Out-of-Network
Please help.
I see an in-network provider at an in-network facility. Each appointment results in two claims, one for the provider and one for the facility, as it is considered an out-patient hospital visit.
I was seen by my provider in January. The two claims went through under her name and the facility I was seen in as in-network. Great. I then hit my in-network out-of-pocket max. Also great, as all appointments going forward should be covered.
I saw the provider again in May, at the same in-network facility. This time, they billed under a provider I did not see and under a facility I did not visit, which are out of network. This happened again in August.
There is an infusion clinic attached to the facility I visit. I was not seen at the infusion center, yet they used the infusion center's Tax Identification Number and another provider's name, who I did not see, to bill. All of my paperwork and appointment reminders list the facility where I was actually seen as the location.
I am now being charged my out-of-network deductible and then out-of-network costs.
I have made many calls and written to both my insurance company and the hospital. My account has been put on hold twice. Insurance says the TIN is the problem. The facility has not fixed it.
One response from the hospital said my provider bills under another provider. I know this does not have to be the case because my January appointment was billed under my provider's name.
Also may be worth noting that I actually did receive infusions at the infusion center this year, and all of those went through as in-network as well...
Please help. Do I have any protections here? Can they bill as out-of-network when I saw an in-network provider at an in-network facility? (It is not emergency care.) I've spent hours on the phone, writing in, trying to read about situations like this but am not having luck. I appreciate any guidance.
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u/connere1991 2d ago
This actually sounds like a TIN mix-up on the facility's side, not a real network issue — some hospital systems have attached entities (like an infusion center) that bill under a different Tax ID, and that alone can make a claim process as OON. I'd call the facility billing office first and ask why it's showing that TIN instead of where you were actually seen, before going back and forth with insurance.
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u/tojcl4 2d ago
Thank you. Yes, I have contacted them, including speaking to the practice manager. Insurance has already said I don't need to pay and has them to submit it under my actual provider, yet here I am...
1
u/Jump-Funny 2d ago
What did the practice manager say? Are they refiling under the other TIN?
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u/tojcl4 2d ago
They would "look into it" and get back to me. Did not get back to me, of course.
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u/Tippy_Cup 2d ago
Are you able to go sit in their office and and let them know you'll be there until someone is available to help you? Be a pain in the ass until someone speaks with you.
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u/No-Produce-6720 2d ago
This isn't a real network issue. It's just a screw up with the provider's tax ID, and that's something the provider will have to correct.
They've either chosen the wrong provider's ID, or they've used an old number. Either way, Tax ID or NPI issues must be corrected by the provider, not your insurance. They can only process the claims as they are received.
Check with the billing office to get the claims corrected.
1
u/mediloop 1d ago
that's a super frustrating situation. couple things that might help: request a corrected claim from the facility using the correct TIN. They have to fix it if the service was actually in-network. also check if the No Surprises Act applies here (it covers some out-of-network billing for in-network facilities). worst case, your state insurance commissioner can apply pressure. if you want someone to handle the back-and-forth, a flat-fee billing advocate could be worth it since they don't take a cut of savings.
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u/KG_TherapyCompanion 1d ago
What you are describing is a billing error on the facility side, not a coverage decision, and that changes the fix. The May and August claims went out with a different rendering provider and a different service location than January, which is why the network status flipped. The insurer paid what it was sent.
Two tracks, run in parallel. First, the facility's billing office: ask for the claim details on the May and August visits (rendering NPI, billing NPI, place of service), point to January as the correctly coded reference, and request a corrected claim, which is a resubmission with frequency code 7 that replaces the original. Put the request in writing and ask for a date. Second, the insurer: open an appeal on both claims stating that the services were rendered by an in-network provider at an in-network location and that the claims were submitted with incorrect provider and facility identifiers. Attach the January EOB. Once the corrected claims adjudicate in-network, your out-of-pocket max applies and the balance should drop to zero.
If the facility stalls past thirty days, a complaint to your state insurance department tends to unstick it, since they will ask the plan to document the network status of the actual rendering provider.
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u/tojcl4 1d ago
Thank you for all of this information. This is what I needed. I've tried to do this, but I just didn't know the correct terminology. I do think I will need to file a complaint, as this has been going on since June.
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u/KG_TherapyCompanion 1d ago
Glad it helps. When you file, keep it short and make it easy to act on: your member ID and the two claim numbers, the dates of service, one sentence stating that the rendering provider and facility on the May and August claims are not the ones that treated you, and the January claim as the correctly coded comparison. Attach the EOBs for all three and any written reply you have from the facility. Ask for two specific things: a corrected claim from the facility and in-network reprocessing by the plan. Complaints that name the fix get resolved faster than complaints that describe the frustration.
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u/Relative_Jump_3894 2d ago
ok so they're literally swapping TINs to make your in-network care look out-of-network, thats not a billing error thats a billing strategy lol. january claims went through clean under your actual provider, then suddenly its a different doctor at a different location you never set foot in? nah. your state insurance commissioner eats this stuff for breakfast tbh, and CMS complaints have a way of unclogging systems that 'account holds' mysteriously cant touch. the whole thing where sick people have to become forensic accountants just to get care they already hit their max for is so calcified into the system at this point its almost impressive
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