If you have a Medicare Advantage Plan or some other individual or employer-provided health insurance that requires you to pay a higher percentage of fees for a doctor or hospital that is out of your insurer’s network, this is a definite case of “buyer beware.” More and more out-of-network providers are charging consumers exorbitant amounts for their services, a new report points out. In one instance, a patient was charged $60,000 for a gallbladder surgery after the insurer had paid the doctor only $2,000—the going rate for this operation when performed by an in-network surgeon. The doctors and hospitals can get away with such huge fees because there are no regulations on how much a patient can be charged if he/she is insured by a company that has no agreement with the provider. To top it off, even if the hospital is in the network, the doctor providing the services there may not be and can charge whatever he wants!
Fortunately, there are some steps you can take to avoid receiving a wallet-emptying bill from an out-of-network provider. My advice…
Unless it’s an emergency, it’s crucial for you to ask any doctor or hospital before receiving care whether the services will be considered “in network.” Caution: Do not rely on the insurance company’s printed lists of providers. Many are outdated—and protect the insurers and doctors with small-print disclaimers. If a provider is not in the network, ask that provider in advance for the exact amount you will be charged for the services. Insider tip: If you are traveling and need out-of-network medical care, don’t assume that your insurer will consider it an emergency and pay the entire bill—even if you’re treated in an emergency room. Make sure the hospital or doctor you see submits documentation to your insurer noting that your care was truly an emergency. Otherwise, you will be liable for the out-of-network balance.
Sometimes, going to an out-of-network provider is your only good choice. For example, perhaps you need a type of surgery or other treatment that is available only from an out-of-network doctor. In these cases, you may be able to negotiate with your insurance company. Insider tip: If your insurance is provided through your employer, your company’s human resources department often can negotiate on your behalf with the insurer for full coverage of specific out-of-network services in which a compelling case can be made. If you want to see an out-of-network provider for routine care, you also can try to strike a deal with him on your out-of-pocket costs before you receive the care.
Most insurers, including Medicare Advantage Plans, have made special in-network arrangements with renowned medical centers, such as the Cleveland Clinic or Mayo Clinic, that are outside their normal service areas. Ask your insurer for a “list of covered facilities,” and check to see whether there are any restrictions—for example, you may need a referral from an in-network doctor. Also make sure that all services and doctors at those facilities will be covered.
