Last week, the New England Journal of Medicine published a comprehensive report on something thousands of health care consumers have been grappling with for years: surprise out-of-network medical bills.
Take the woman in Charleston, South Carolina, who underwent an emergency C section. The in-network anesthesiologist wasn’t available, so she faced a $15,000 bill for the out-of-network doctor who replaced him.
Or consider the man from Grapevine, Texas, who underwent an emergency appendectomy with an out-of-network surgeon — the one who was on duty at the time. His bill: $950.
So-called surprise billing comes about when patients visit a hospital or emergency room that’s part of their insurance company’s network, but then they receive care from a doctor or other provider who isn’t part of that network. That provider sends a bill directly to the patient, usually for the difference between the in-network contracted price and the provider’s full fee.
The authors of The New England Journal of Medicine study looked specifically at surprise billing in ER situations. They found that 22 percent of the time, patients who went to the ER at a hospital covered by their plan received treatment — and a bill — from an out-of-network doctor
These unexpected out-of-network bills can be part of any hospital stay, planned or emergency, said Betsy Imholz, special projects director at Consumers Union. That may be true even for people who know they’re going to the hospital — for a planned surgery, for instance, or to deliver a baby — and have been scrupulous about making sure they would be fully covered for the treatment.
“I’ve seen out-of-network bills from assistant surgeons who check on the patient while they’re still unconscious,” Imholz said. “The patient never even knew the doctor was there. It could be the anesthesiologist or a radiologist. There are so many people that touch you medically when you are in the hospital.”
How can a doctor or other provider treat you at an in-network hospital but not be part of that network? “It’s important to remember that doctors are rarely employed directly by the hospital,” Imholz explained. Instead providers or groups of providers contract with insurers separately. The insurers the providers work with may not be the same insurers that contract with your in-network hospital.
So even if you’re admitted to a network facility and billed network prices for those facility charges, you may be treated by out-of-network doctors and other providers who have their own, higher fees.
What can you do if you’re on the receiving end of surprise billing? Imholz and other experts offer this advice.
Don’t pay right away. Worried that an outstanding medical bill could affect their credit rating, patients who can afford it often simply pay the bill without questioning it. Frankly, that’s what a lot of health care providers hope you’ll do. While it’s true that medical bills sent to collections can dramatically affect your credit score, the process usually takes some time. You have a little breathing room to research alternatives. And beginning in 2018, credit agencies will have to wait 180 days before reporting medical debt.
Check with your state regulator. You may live in one of the 15 or so states that have legislated protections for people who incur unavoidable out-of-network charges. California, Florida and New York, for example, have extended those protections beyond the ER to all hospital stays. Even states without such protections may have resources to help you resolve the problem.
Keep in mind, it’s not always obvious which state office handles these complaints. In New York, for instance, it’s the Department of Financial Services. To find out who you should contact, go to the Consumers Union complaint tool and type in your state. You’ll find the appropriate agency and any nonprofit volunteer organization available that can also help.
Contact the provider who sent the bill. Now it’s time to call the provider directly. Ask to speak to the person in the office that handles billing. Inform him or her of your surprise charges, why you think they are unfair and any protections in your state that you’ve learned about. Ask the provider to reduce your bill to the amount that would be covered if the provider were in your network. When pressed, providers will often lower the bill.
Contact your insurer. At the same time you contact the provider you should also talk to your insurer. Billing errors are ubiquitous in the health care industry. You may find that what you thought was a balance owed is actually a clerical error due to mountains of paperwork, shifting networks, improper coding and other bureaucratic problems.
If the solution isn’t so simple and your provider won’t negotiate, you may find you’ll need to file an appeal asking your insurer to cover the out-of-network costs. Many states have rules saying insurers must have adequate provider networks to cover a wide range of health issues. If they don’t, they must cover the out-of-network costs, explained Imholz. Yours may be such a situation.