How to Avoid “Out-of-Network” Medical Bills


If you or a family member have to undergo a medical procedure, you’re probably already feeling stressed. The arrival of an unexpected bill in the days that follow can feel like the last straw, especially if it’s an “out-of-network” bill from a provider whom you saw at your “in-network” hospital. Read on to learn how to avoid these extra charges if you can, and how to deal with the ones you can’t avoid if you can’t.

Why it Happens

Hospitals are complex hives of activity, and many different practitioners provide services within their walls. It would be simple if every person treating you during a hospitalization was an employee of that facility, but unfortunately, that’s not how it works. Instead, intricate webs of provider networks converge in every hospital, and the bill one patient receives is probably completely different from the bill received by the patient in the next room for the identical procedure. Your insurance plan may cover the hospital, and your PCP and surgeon may be part of your provider network, but 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 and your insurance plan may cover very little of that bill because it’s “out of network.” What’s even worse, paying that bill usually doesn’t count toward your insurance plan’s deductible or out-of-pocket maximum.

You’re Not the Only One Who Thinks This is a Problem

It may not bring you great comfort if you receive a large and unexpected medical bill, but some movers and shakers in the health insurance field have recognized balance billing as a situation consumers need protection from. At this time, seven states (California, Colorado, Florida, Maryland, New Mexico, New York and Texas) have enacted special laws to protect their citizens. Other states may follow suit soon, so it’s worth keeping tabs on developments in your state.

How to Prevent (Some) Balance Billing

While you can’t completely eliminate the risk of balance billing, 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 is covered by your insurance plan. You can go online to view your plan’s provider network, but you should also phone your plan to double-check the accuracy of what they have on their website.
  • Before you receive any care, ask the doctor or lab or other facility if they are part of your insurance plan’s provider network. This is different from asking them if they “accept” your insurance. Even if they are out of network for you, they may tell you they accept your insurance, but that doesn’t mean you’ll be covered for much of their charges.
  • Bring an advocate with you to the hospital, and ask that person to have an ongoing conversation with your insurance plan and hospital personnel in an attempt to minimize the accidental use of out-of-network providers.

How to Ease the Pain of Receiving a Balance Bill

  • If you do receive an unexpected 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 be resolved in accordance with the law.
  • 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 own physician to call on your behalf; sometimes providers will be flexible with each other’s patients in order to preserve a good referral relationship.

Our licensed brokers would be happy to you understand your in-network options. Make an appointment with us today to answer all of your questions.

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