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?
Even if your hospital participates in your health plan, that doesn’t mean that all the providers working there do, too. If you need surgery, or have a serious illness, there may be several providers involved in your treatment. And each of them may contract separately with insurers.
When you receive treatment in a hospital, be aware that you may get a bill from providers who don't participate in your network, such as:
Surgeons assisting your in-network surgeon
What Can I Do?
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. In that case, you’ll get a “balance bill” from your provider for the difference between your plan’s payment and your provider’s fee.
The best way to try to avoid this situation is to talk to your doctor and your insurer first. Find out if all the providers involved in your care participate in your plan before you schedule your procedure.
While you could try to negotiate after you've already received the bill, out-of-network providers are under no obligation to accept a lower payment.
What about Emergencies?
If you’re in a car accident, suffer a heart attack, or have another emergency, you may not have a choice about where to go for care. You’ll usually be taken to the nearest hospital, which may not participate in your network. And even if it does, some of the ER doctors or consulting specialists who are called in to care for you might not participate in your plan.
Waiting to get care in an emergency can be life-threatening, so most plans cover emergency care no matter where you are – even if the hospital does not participate in your network. Once your condition is stable, you will generally be moved to an in-network facility for follow-up care.
But remember, that only applies to real emergencies. Emergency room visits cost more than regular doctor visits, and insurers often won’t pay certain emergency costs if it’s not a true emergency. Most plans are required to abide by the “Prudent Layperson Standard” under PPACA, which defines a medical emergency as “A condition with acute symptoms of sufficient severity (including severe pain) that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in—(i) placing the health of the individual (or an unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part."
If you’re not sure what constitutes an emergency, or what emergency costs are covered, ask your insurer.
Your Action Plan: Be Prepared
Before Your Surgery: Speak Up
When you and your doctor are planning your surgery, tell him or her if you only want to use in-network providers.
If your doctor has specific providers in mind that he or she usually works with, check with your insurer to make sure they are in your network.
If one of your doctor’s picks is not in your network, you can ask your doctor for a different provider who is. Or, if you decide to stick with your doctor’s choice, you may want to try to see if you can negotiate a reduced fee in advance. Then, call your insurer to see how much of the cost your plan will cover.
When you call your insurer to pre-authorize your surgery, ask if there is anything you can do to avoid being balance billed.
When you are arranging for your admission and providing information to the hospital, include a request that any doctors assigned to your case be in your plan’s network. As the hospital admissions staff puts together your record, ask that this request be a part of that record and ask that it be included in any forms you sign.
After Your Surgery: Is there anything you can do?
If you’ve already received a bill, you may still try to negotiate, although, there is no requirement that your insurer or provider agree to a lower rate.
You can try calling your insurer, since your insurer may be able to negotiate with your doctor to accept their rate as payment in full, or at least to lower the fee.
You can also try discussing this with the doctor.
Of course, when you use out-of-network providers, even by accident, they have no obligation to reduce their fees. That is why it is often best to know if all of your providers are in your plan's network before you get the care.
In an Emergency: Focus on Your Care First, Then Call Your Insurer
Once your condition is stable, call your insurer or have a friend or family member make the call.
If you have a Primary Care Physician, (PCP) contact him or her. Your PCP can then make sure you’re getting the care you need, and transfer you to an in-network facility if necessary.