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CO-PAY RISING
Navigating the Healthcare Maze
When In-Network Providers Surprise You With Out-Of-Network Costs
by Lisa Zamosky
Q.I recently underwent surgery at a hospital that is participating in my health plan's network.
I just got the hospital bill and am only now learning that while the hospital is in-network,
many of the doctors I saw and services I received during my stay were not. Now I'm being charged a fortune! What's going on?
A. Just because the hospital where you have surgery is in your insurance company's provider network does not mean that all doctor visits,
lab tests and other services are covered. Any doctor's visit or service provided by someone not in your health plan's
provider network during your stay will result in a bill.
Behind the scenes: Confusion about provider networks leads to financial headaches
for most insured people. Patients don't have a choice about whom they're treated by in the hospital,
so it's not uncommon to receive unexpected bills after a major procedure. If the provider who treats you
is not in your insurance company's network, you are effectively uninsured at that point and have to pay bills for doctors you didn't necessarily
agree to see.
That means that before you go to the hospital, it's up to you to ask in advance if everyone involved in your treatment is in-network.
Assuming your surgery is elective, ask a lot of questions ahead of time about coverage of both doctor visits and medical tests.
If possible, designate a friend or family member to oversee financial matters and ask about all charges, bills and services.
What to do: Fight the charges. If you didn't have a say in selecting the out-of-network providers
who treated you during your hospital stay, you shouldn't be responsible for paying their charges at an out-of-network rate.
As a first step, contact your insurance company's customer service line to ask for help rectifying the situation.
You can find that number on the back of your insurance card or on the company's website.
If you have any trouble getting the charges transferred from out-of-network to in-network prices,
initiate your health plan's internal appeals process. You can obtain the procedures directly from your health plan, or find information here:
FamiliesUSA.org.
If you get health insurance through your job, you can also ask your human resources department for help. Just be aware
that there are time limits placed on appeals, so don't delay. Under Federal law, an employer-sponsored health plan gives you 180 days to file an appeal.
But there are other timelines, which differ by plan.
Take action: If all else fails and the charges are not dropped, don't pay the full amount; negotiate with the provider.
They'd rather get paid some amount of money right away than hope that the full amount will ultimately be paid over time. Use that to your advantage and make them an offer.
If you have no idea where to start in your bargaining, visit the Centers for Medicare and Medicaid Services.
Medicare payments are a baseline for the rates health plans negotiate with doctors. Use these rates as a starting place and get to haggling.
Best of luck!
If you have a healthcare question you'd like help answering, please send your query to Lisa at lisa@writtenarts.com.
Lisa Zamosky is a writer specializing in healthcare and a former executive who worked for years in the health insurance industry.
Visit her online at Writtenarts.com. E-mail Lisa at lisa@writtenarts.com.
*The opinions stated aren't necessarily those of MommaSaid or its principals. Seek professional advice before beginning any health program.
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