Out-of-Network Doctors at In-Network Hospitals

According to Becker’s Hospital Review, 57% of Americans have received a surprise medical bill even after going to an in-network hospital for medical treatment or surgery. Balance billing, as this practice is sometimes known, can quickly result in overwhelming medical debt in spite of having a robust insurance policy.

Problems with Out-of-Network Doctors

You really needed surgery, so you made sure that the doctors you saw in preparation for your surgery were in-network, your surgeon was in-network, and the hospital itself was in-network. Then you started getting the bills — bills that were not from the hospital. It turns out that your anesthesiologist was not in-network and your insurance (which many consider a top of the line plan) only covered a fraction of what was charged. Now you have some seriously unexpected medical debt.

blood test

Here’s another example: you suffered a serious leg fracture but still had enough presence of mind to insist that you be taken the emergency room at a hospital that you know for a fact is in-network. A few months later bills start coming in: the radiologist that was responsible for your x-rays was out-of-network, and so was the orthopedic specialist who diagnosed your fracture. Now you have bills coming from out-of-network medical providers who were providing services to an in-network hospital emergency room. Your health insurance pays for part of the bill, but you are still responsible for the balance, which can easily be thousands of dollars. While you had some money set aside for medical emergencies like this, it will not cover what these out-of-network providers are charging.

Surprise Billing

In-network hospitals with out-of-network doctors are one of the forms of surprise billing. In fact, there are cases where an out-of-network anesthesiologist group is the only provider of such services at an in-network hospital. The epidemic of surprise billing is rapidly getting out of hand and is actively contributing to the level of medical debt in the United States. And it seems that the healthcare services most associated with surprise billing are anesthesiology, medical imaging (e.g., radiology, x-rays, sonograms, CAT scans, MRIs), and laboratory work. Trying to prevent charges from out-of-network providers is extremely difficult when you are ill and is compounded when you have to visit an emergency room or find yourself in the hospital.

medial lab test

Legal Measures to Control Surprise Billing

The problem of surprise billing is currently being dealt with at the state level with New York being the first to implement legislation aimed at regulating surprise billing, followed by Florida and California. They were the first three of a total of nine states that are actively working to put an end to surprise billing. As of 2017, more than half of the states had done nothing to protect consumers from surprise medical billing.

And while states are the main source of protection, state laws do not apply to people who have “self-insured” plans through their employer (about 60% of insured people in the US) in which the employer (usually a large company) assumes the financial risk for providing health care benefits to its employees. These plans are regulated at the federal level and only federal law can protect them from surprise billing regardless of which state they live in.

However, the US Senate is currently looking into ways to prevent surprise medical billing, among other healthcare reforms.

What to Do to Prevent Surprise Medical Bills

There are certain measures you can take to prevent surprise medical bills. Make sure your primary care physician knows that you only want to see in-network health providers. In addition to this, always check with your health insurance company before seeing a healthcare provider in order to verify that the provider is actually in-network. As an extra level of precaution, talk to your insurance company to find out what you can do to avoid being balance billed. If you end up in the hospital, ask the hospital to please avoid assigning out-of-network healthcare providers to your case. And remember to pay special attention when it comes to medical imaging, laboratory tests, and surgery.

medical bill negotiation

What to Do After Receiving a Surprise Medical Bill

If you received a surprise medical bill, your best approach is to try to negotiate with the billing office of the out-of-network provider, but keep in mind that they are under no obligation, legal or otherwise, to reduce your bill or accept lower rates. However, you can check with state law to see if your state provides you with any protections.

Conclusion

Surprise medical bills are a nightmare and can result in thousands of dollars of medical debt. While there are things you can do to prevent surprise medical bills, medical emergencies can quickly wrest that control out of your hands. Once you have received a surprise medical bill, you can try to negotiate it down, but unless your state regulates surprise billing, there is not much that you can do alone.

Consumer Medical Bill Solutions

At Consumer Medical Bill solutions, we know that surprise medical bills can quickly become overwhelming, and not everyone has a natural skill for negotiating. That’s why we offer the services we do: our skilled team can significantly reduce your medical bills by negotiating on your behalf. A consultation with one of our team members, a release form, and documentation of your medical bills will allow us to start helping you. Let us do the negotiating so that you can concentrate on getting well! Contact Consumer Medical Bill Solutions today!