Out-of-Network Docs at In-Network Facilities
Suppose you receive care in a hospital that is in your health plan’s provider network. You may still get a bill from providers who treated you at the hospital but are not part of your plan’s network. If you are getting surgery, out-of-network providers may include radiologists, anesthesiologists, pathologists and surgeons helping your in-network surgeon.
Your plan may not cover any out-of-network care, leaving you to pay the full cost. Or, they may cover part of the cost, but at a much lower rate than the provider charges. You may have to pay the difference.
How can you avoid getting such a “surprise” or “balance” bill? Tell your doctor in advance that you only want to use in-network providers. If your doctor has specific providers in mind, check with your insurer to make sure they are in your network. Ask your insurer what you can do to avoid being balance billed. Ask the hospital to see that any doctors assigned to your case are in your plan’s network.
If you have already been balance billed, you can try to negotiate. But, your provider is not forced to take a lower rate. New York State has special protections for consumers who are balance billed.
Most plans cover emergency care no matter where you are. They do that even if the hospital is not part of your network. But, it has to be a “true emergency,” not routine care.
I Stayed in My Network….Why Did I Get a Bill?
You’re scheduled for surgery, and you’ve done your homework. You know that your doctor is admitting you to a hospital in your plan’s network. You’ve checked that the surgeon participates, too. Your insurer has pre-authorized the service. You’ve put aside money to cover your copayment. So, there shouldn’t be any surprises, right?