The latest health-care trap: What starts out as an in-network hospital visit fully covered by insurance turns into a surprise out-of-network bill for hundreds or even tens of thousands of dollars. That’s what many patients are discovering after they undergo treatment and/or surgery, especially in emergencies. The reason: Doctors and hospitals belonging to your insurer’s network may use out-of-network specialists, consultants, assistants and other hospital employees without you knowing it. The insurer then covers only a small portion—or none—of the out-of-network provider’s fee, and you are billed for the rest. Example: One ER patient got a bill for $937. Insurance paid $151.02. The patient owed $785.98.
Patients typically don’t realize they are authorizing this when they sign hospital consent forms. Unlike in-network providers who agree to discounted rates negotiated with the insurer, out-of-network providers charge their full fees, which may be 20 to 40 times higher.
There is some legal protection. Medicare doesn’t allow providers who accept Medicare payments to bill patients beyond what Medicare covers. And 13 states have a variety of restrictions on whether and how much patients can be charged for medical services such as anesthesia that often are provided by out-of-network providers.
To protect yourself…
• Know which hospitals are in your network in case of an emergency. Then ask what percentage of ER doctors and other personnel there are out of network. If most are out of network, consider choosing a different hospital.
• If you’re having a planned procedure, ask your doctor well in advance who else might be involved in your case, and insist that everyone be in-network unless there is an overriding need for someone out of network to take part. Seek to work out terms in advance with out-of-network providers.
If you do face out-of-network fees…
• Your insurer may be willing to cover more of the cost and/or convince the provider to lower the bill. You also can file an appeal with the insurer.
• Ask your state attorney general to intercede.