A Westchester, CA mom expected to pay about $320 in co-pays and coinsurance when she took her son to a nearby hospital for an ankle injury, because she was very careful to go to a hospital that was in her insurance network. Imagine her surprise when she received a bill for $1,400 from the emergency room physician. Although the physician worked at her local in-network hospital, he wasn’t included in her insurance plan. And even though she couldn’t have known that, it turned out the charge was entirely legitimate and she had to pay it.
Nearly 25% of Californians who seek healthcare services at “in-network” facilities are shocked to receive surprise bills that are not covered by their health insurance. The practice is called “balance billing.”
When Networks are “Notworks!”
Balance billing occurs when physicians at in-network hospitals and urgent care centers are not included in the same health insurance networks as the medical facilities where they work. These doctors are called “non-participating providers,” referring to the fact that they do not participate in the same insurance plans as the hospital does. In fact, their services are billed separately from the hospital.
This is especially concerning since now, more than ever before, people are aware that their health insurance policy limits their coverage to services at specific hospitals or from specific medical providers.
Yet even when they are very careful to go to a hospital within their health insurance network, patients often have no way to find out whether the radiologist or the emergency physician will be covered by their health insurance plan since the lists of in-network providers change frequently and are often inaccurate.
Even doctors themselves can be unsure which insurance plans cover their services because insurance companies have scores of different insurance plans with multiple networks that apply to different doctors and medical groups. As an example, Aetna Insurance offers the following plans: Open Access HMO Network Plans, PPO Network Plans and “subplans” like Aetna HealthFund HDHP w/HSA, Aetna Direct, Aetna Value Network and Aetna HealthFund CHP Select, each with its own mix of providers and in-network services. Is it any wonder a person would be confused?
Balance Billing: The Biggest Sting of All
Charges for out-of-network services are often extremely high. A 2014 NY Times article reported on a patient who received a bill for $117,000 from a neurosurgeon whom he had never even met! The non-participating neurosurgeon was called in as a consultant on the patient’s back surgery at Lenox Hill Hospital.
This is a practice called “drive-by doctoring,” and patients usually have no clue that an unknown doctor is involved in their care until they get the bill. And because balance bills are not processed through the insurance company and the rates are therefore not negotiated, these bills are the highest of all!
Simple is best.
All medical providers including doctors, hospitals, clinics, physician assistants, labs, etc. should be “in-network.”
With a universal, single payer system, people seeking medical care won’t face the challenge of figuring out where to go for care or the sting of surprise medical bills!
Learn more:
http://www.latimes.com/business/la-fi-healthcare-watch-20150717-story.html
http://www.aetna.com/docfind/jsp/rdIndex.jsp?site_id=fehbp&langpref=en
http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html?_r=0
