How to avoid an out-of-network medical bill

If you or a family member have to undergo a medical procedure, you’re probably already feeling stressed. When an unexpected medical bill arrives afterward, it can feel like the last straw. Especially if it’s an “out-of-network” bill from an “in-network” provider. Read on to learn how to minimize your chances of receiving an out-of-network medical bill and how to deal with the ones you can’t avoid:

Why you may receive an out-of-network medical bill

Hospitals are complex hives of activity and many different practitioners provide services within their walls. It would be simple if every person treating you was an employee of that facility but unfortunately, that’s not always the case. Instead, there’s usually a complex web of provider networks in every hospital. For example, you have a surgery and your primary care doctor and surgeon are a part of your provider network. However, the anesthesiologist who handles your procedure may have no connection with your insurance plan. When this happens, you get a separate bill, called a “balance bill“, from the anesthesiologist’s office. Your insurance plan may only cover a small amount, if anything, because it’s an out-of-network medical bill. And what can make it worse is the bill usually doesn’t count toward your insurance plan’s deductible or out-of-pocket maximum.

You’re not the only one who thinks out-of-network medical bills are a problem

Policymakers realize that “surprise medical bills” are an issue and are starting to address this problem. Within the last few years, some policies have been adopted that 1. Limit or prohibit “balance billing” or 2. Require the provider or health insurance plan to disclose this information to the consumer in advance. Special laws have also been passed in a small number of states (California, New York, Texas, Florida, plus more) as a way to protect their citizens. Other states may follow suit, so it’s worth keeping tabs on developments in your state.

How to prevent (some) balance billing

While you can’t completely eliminate your chance of receiving an out-of-network medical bill, you can take some effective steps to minimize its likelihood:

  • Check ahead of time to see if every health care provider and facility you expect to use accepts your insurance plan. Tip: Call your provider directly to verify any information you find online. This may be outdated so it’s a good idea to double check.
  • Before you receive any care, ask the doctor or lab if they are a part of your “insurance plan’s provider network”. This is different from asking if they “accept” your insurance.
  • Bring an advocate with you to the hospital. Ask that person to have an ongoing conversation with your insurance plan and hospital personnel when you’re unable to do so yourself.

How to ease the pain of receiving a balance bill

  • If you do receive an out-of-network medical bill, first contact the facility’s billing office and ask if there was a coding error.
  • Next, contact your state insurance commissioner’s office and see whether your state has any protections against this practice. If so, call your provider and request that the bill is resolved in accordance with the law.
  • Finally, you can also call the provider who generated the charges and explain the situation. Occasionally, they will waive charges that you couldn’t have prevented. You can also ask your physician to call on your behalf. Sometimes providers will be flexible with each other’s patients in order to preserve a good referral relationship.

Still have questions about out-of-network medical bills? Our Consumer Advocate team is happy to answer any questions you have around your health insurance plan. Call us today at (855) 772-2663.

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