What To Do When Out-of-Network Medical Bills Strike

by | Jan 15, 2018

Many people take the time to research which local medical centers or hospitals are covered by their health insurance plan well before a serious issue arises. Regardless of whether you are dealing with an emergency medical issue, or heading to a hospital for a planned surgical procedure, you understandably expect that any care that you receive while in an in-network medical center or hospital will be covered under the terms of your health insurance policy. However, there are many times when patients have received high bills for out-of-network services even though they received treatment at an in-network medical facility. Whenever you go for treatment, it is important to verify that your attending physician is covered by your insurance plan, as well as the facility.

High Costs at In-Network Hospitals Result in Out of Network Medical Bills

Being charged for out-of-network service at in-network hospitals occurs occurs more often than you might think. In Texas, for example, the state’s largest insurers are Aetna, United HealthCare, and Blue Cross Blue Shield of Texas. Research indicates that almost half of all emergency room physician service claims were not in-network with these or other insurers. At the same time, research also shows that 98 percent of patients with coverage went to an in-network hospital for emergency services. This issue is not unique to Texas, and it can result in patients’ medical bills being two to three times higher than they otherwise would be.

One patient advocate group in Austin has been studying this issue. Unfortuantely for patients, both insurance companies and physicians are stuck in a round-robin game of finger pointing. Physicians at hospitals say that insurance companies offer only a very low rate of compensation, so they have no other option except to be out-of-network. Some physicians say that insurance companies often will not return their calls when they try to get in-network with them, or the insurance companies offer such low compensation that their own expenses for treatment are not fully reimbursed. Essentially, the doctors are forced to pass the cost on to patients. Insurance companies, on the other hand, say that doctors are refusing their payments. In addition, hospitals are simply trying to stay out of the matter by saying that they have no control over the situation.

Out of Network Medical Bills: Accidental or Intentional?

However, some sources indicate that this problem, especially in emergency services, is intentional. When evaluating other types of medical services and healthcare environments, patients can find out beforehand if the treatments and services are covered by their health insurance policy. They may specifically research providers who are in-network, and they may even seek approval from their health insurance company for specific procedures or services. In an emergency room environment, however, patients usually have no time to research every individual healthcare provider that may treat them or contact their insurance company for approval for services and treatments. In this unique situation, doctors may take advantage of the situation in emergency rooms to earn more compensation. While not all doctors in emergency rooms are out-of-network, the study indicates that are a larger number of them are. Moreover, more physicians in this specialty area may be out-of-network than in many other specialty areas.

When patient advocate groups make inquiries to these medical professionals, they receive different responses from physicians. Some claim that they have no ability to check each patient’s health insurance state before treating a patient. This is particularly true in the hurried and time-sensitive environment of an emergency room. Others who speak to a health advocate may say that they try to be in-network with as many insurance companies as they reasonably can be. However, it is not feasible for each physician to be in-network with all insurance companies. Some said that they sympathize with patient frustrations, but patients should be aware that visiting a hospital does not give you an in-network package deal. Each professional or company that you are treated by at the hospital may have an independent billing system.

For non-emergency room doctors and other healthcare professionals, insurance companies may offer a generally low rate. Because non-emergency room medical services are easier for patients to shop around for, these service providers may feel the need to accept a lower rate from insurance providers even when they do not feel that the rate is just. In the emergency room environment, however, medical professionals understand that their patients cannot shop around. Therefore, they do not feel the need to accept an insurance company’s low rate of reimbursement. With this in mind, some providers may choose to be out-of-network in order to earn a fair wage.

The unfortunate reality is that this is a very common problem, especially in Texas. While the state has passed laws in recent years that help to reduce a patient’s out-of-pocket expenses related to emergency medical procedures and healthcare services, many are still being billed unfairly. For example, in some hospitals, drive-by doctoring occurs when patients are under anesthesia and have no control over who sees them or treats them. Some patients even have routine medical procedures with all apparent aspects of the costs approved by insurance beforehand. However, assistants or specialists may be called in for advice or oversight, and these individuals may not be under the individual’s health insurance plan. More than that, the additional medical oversight may not even be needed.

Let a Patient Advocate Help You Navigate Out of Network Bills

Working with a patient navigator can help you to better determine which charges you should actually pay for and which charges you should dispute. In some cases, a patient advocate has helped patients to negotiate hospital or physician charges dramatically lower. In other cases, a health advocate has been able to get insurance companies to pay for more of the charges.

It can seem like you are alone in your fight related to healthcare costs. You may even feel like you are caught in a ping pong match between providers and your insurance company. If you are dealing with a stack of medical bills that you believe are higher than they should be because of an out-of-network issue, help is available through a patient advocate. Contact Values Based Patient Advocates for more information.

Our Patient Advocate Office is ever just an email or phone call away: 703-222-1300 – we’re happy to help! A phone call is free and it could save a life or reduce a large hospital bill.

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