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 This may be outdated so it’s a good idea to double check.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.
And finally, to help you avoid an out-of-network medical bill, we created a free guide that you can save for future reference. Click here to grab it.
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Hi,
What if…
A provider is contracted with an Medicare Advantage (MA) plan. The MA plan is offered in more than one network. One they are contracted with, the other not. A patient is advised that seeing a specialist out of network bears patient financial burden. The patient signs an agreement for financial responsibility. Once billed, the patient calls there plan to complain. The plan calls the provider and states they are not allowed to bill patient because patient is an MA member.
Is the plan correct or incorrect?
That’s right, when you’re in the operating room receiving anesthesia and your tongue is hanging out of your mouth like a German Shepherd dog, don’t forget to ask everyone in the room if they are “in network.” If anyone says “no,” firmly demand that they step away and find an “in network” substitute who can fill in at a moment’s notice.
This is the American way of health care, a ingenious system designed to stick it to the consumer in as many creative ways as possible. As long as providers and insurers get their profits, all is okay.
All Medicare Advantage &/or PPO recipients need to know this:
My HUMANA PPO wrote “we do not balance bill”. My “specialist co-pay” is $50. Humana contracts Georgia Wellstar as being “in- plan”. However, in Dec. 2019 I required cardiac clearance to undergo back surgery so I went back to my Cardiologist’s office, was asked for my $50 co-pay, and had an Echo-cardiogram in his office. Recently Wellstar billed me an additional $50 for that test, only the bill listed a nearby hospital as to where it took place, NOT in my physicians office. After over an hour on the phone over 2 calls, I learned this from Humana: Wellstar “owns the equipment”, so they can charge E.R. pricing. THAT IS AN ERRONEOUS PRACTICE, NOT DEFINED BY HUMANA IN THEIR BOOKS, OR BY THE PERSON AT WHO DETERMINED MY CO-PAY AT my MD’s office at CHECK-IN. Furthermore, Georgia just passed laws making hospitals provide a list of charges at sign-in, before you undergo ANY treatment. First, I never entered the Wellstar E.R. at the COBB WEST hospital listed on the “balance bill” from Wellstar, and if they claim I did, why didn’t they take $100 at sign-in (not the $50 I was originally charged)? Second, why did my heart physician only accept $50 originally, at the time of service? These corporations are about money, not my health…or yours, really.
In my opinion, this practice by Wellsta is an “end run” around the State of GA legislating that hospitals must provide a line item “cost of services” to patients. It’s unethical and a money grab for charges and “doing business as usual” despite the laws of GA…how can anyone be obligated to pay more than the fee their Plans E.O.B.’s states, or they are informed they are responsible for at the time of a procedure? Please, someone explain this deceitful practice to me.