In-Network Doctor charging "Admin Fees" for billing Insurance in CA

There was an older post about this earlier from a few years ago, so I thought I would share my own research into this matter. If you are in network, per the CA Insurance Commissioner / Department of Insurance: Consumers can only be billed for their in-network cost-sharing (co-pays, co-insurance or deductible), when they use an in-network facility for non-emergency care. I read this as "you can't be charged admin fees if you are in-network." Someone please correct me if I'm wrong.

https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm

https://www.insurance.ca.gov/01-consumers/101-help/index.cfm

Backstory:

I was desperate to resolve a health issue, found an in-network doctor who could see me in a week (all other specialists in his field had 2-3 month waiting periods for their next available appointment). I honestly thought I was super lucky because he's associated with a prestigious hospital here and he had mostly glowing reviews on most platforms that I checked. I did note that there were a few reviews about this doctor about shady billing practices tho it was only 1 out of every 10 reviews, everyone else said his treatments were life changing.

His paperwork mentioned that he required pre-payment of services / tests rendered, and I was OK with that as long as he would file the necessary insurance paperwork as he was *in network* and I needed that paperwork for reimbursement from my FSA of which I still had $1.5k to spend before the end of the year.

Provider ordered a few tests, I took said tests, and paid $190 to "cover the test fees because your insurance will definitely not cover it". He also said that any medication that he will prescribe me will only come from this one pharmacy (in a posh part of town) and that he will *NOT* call prescriptions to any other pharmacy (CVS, Walgreens, etc.,)

Lo, behold. I get the EOB, it's fully covered and my insurance says my responsibility is $20. I call his billing department and originally they said it would be used as a credit for ongoing care. I have several follow ups (after initial visit the provider went telehealth only). The doctor's front office charges my credit card $43 out of the blue a few days ago which I thought was weird but before I get to check against EOB…

I get hit with mobile invoices from his medical billing department which all magically match what was billed to my insurance and they are now politely (aggressively) asking for payment from my first visit with the doctor. The $190 + $43 that I've been charged to date apparently did not apply to any invoices even though they acknowledge that they had record of it. They were "admin fees" to which I went but he's in network, pretty sure that's illegal. They refer me back to the main provider line, they're only the medical billers and promptly hung up on me.

I call my insurance and ask them for help, and all they said is the doctor can only bill you what's on the EOB. Talk to their escalation team and sort it out. My work has a healthcare concierge that is supposed to finagle complicated billing issues, so I outsourced dealing with this doctor and insurance to them. I have also cancelled all future appointments with the doctor.

I've considered contacting the Office of Patient Advocacy at the hospital he's associated with and the State Insurance Commissioner. Insurance Commissioner requires I exhaust the insurance appeal process before escalating to them.

Good news: I found a new doctor (definitely in network) also belonging to a prestigious hospital group with admitting privileges. She listened, actually ran some tests pertinent to my condition and have a plan for ongoing care. She also answers her emails and I can see my test results on the hospital group app. O and they charged me $0 for my first visit. 🙂

submitted by /u/porcelain_elephant
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