“Excuse me Doctor ― yeah, you with the paddles in your hands who is shocking that heart back to life ― are you an in-network provider?”
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A hospital stay ― or even just an emergency room visit ― is stressful in and of itself. But as patients and their families quickly learn, the actual time spent on a gurney is just the tip of the stress iceberg.

The real gut punch comes when the bills start to appear in the mailbox. There will be bills from people and places you’ve never heard of. These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others who your primary care doctor invited in to feast on the buffet that is you. And if you didn’t understand what the difference was between in-network and out-of-network providers before this, chances are you got up to speed pretty fast.

The in-network provider or facility is a doctor or medical service who contracts in advance with your particular insurance plan and agrees to accept what they pay him. At least in theory, but more on that later. An out-of-network provider has no such agreement and while your insurance will pay him something, you are responsible for a greater chunk of his bill ― plus some extras.

In my husband’s recent month-long stay at a major teaching hospital, doctors and baby docs paraded through his room all day and night long. He saw nephrologists, cardiologists, a guy who specializes in pacemakers, urologists, dietitians, endocrinologists, physical therapists, occupational therapists, surgeons, hospitalists, dialysis specialists, nutritionists, ICU doctors and more. And despite having what is considered excellent insurance coverage and being at an in-network hospital, we are staggering under the weight of bills not covered or not covered fully. By my recent count ― and with more new bills arriving every day ― my husband was seen and billed by far more out-of-network doctors than ones in-network. Even the partner who filled in for his principal in-network doctor turned out to be out-of-network. Same practice, mind you, but separate contracts with insurers. Technically speaking, our doctor took the day off ― something he was certainly entitled to do ― and we got stuck holding the golf bag.

In the emergency room where my husband was brought by ambulance, two of the doctors who saw him were out-of-network. When I called to challenge how we were supposed to know that ― remember, this was an emergency room visit that led to a month’s hospitalization ― I was told I should have asked the doctors. “Excuse me Doctor ― yeah, you with the paddles in your hands who is shocking that heart back to life ― are you an in-network provider for Anthem Blue Cross/Blue Shield?” Yes, absurd to even think about.

A Kaiser Family Foundation study reported that nearly 7 in 10 people with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care. Maybe doctors should wear a badge that says “I take no prisoners or insurance, only your kid’s college fund.”

And the real kick-in-the-ass comes when you realize, it’s not you deciding to be seen by all these out-of-network doctors or having your blood work sent to an out-of-network lab or having your scans looked at by an out-of-network radiologist. No, you have nothing to do with it. But yet you will be expected to pay for it all ― even though you had no say in it.

But the in-network thing is just part of how screwed up this is. There is also “balance billing” ― the evil first cousin of doctors in-network. In this case, an in-network provider who doesn’t like your insurer’s reimbursement rate will still take the insurance company’s money, and then send you a bill for the rest of their desired fee, aka the “balance.” So even when a procedure is covered, you’ll still get bills. “Oh, but they’re not supposed to do that,” you say. And right you are. They are not. In-network doctors who negotiate and agree to accept your insurance are supposed to do just that. Insurance companies hear about it all the time ― and not just from me. But insurance companies aren’t dumb. They know what’s going on and turn a blind eye to it. Why?

Because one thing balance billing does is deter patients from seeing a doctor. Studies have shown that when the patient’s portion ― whether a copay or deductible ― is high, they tend to put off making an appointment for what ails them. That’s a win-win for the insurance company, unless of course, the patient’s condition worsens and they wind up paying more. Clearly a risk they are willing to take.

Balance billing is illegal in some states. Just last year, New York set limits on these surprise medical bills from out-of-network providers in emergency situations and in non-emergency situations when patients receive treatment at an in-network hospital or facility. That won’t help me in California, but isn’t this a problem that should be addressed on a national level anyway?

Unfortunately, there are plenty of billing issues that are unfair but still legal, says the Medical Billing Advocates of America (MBAA). For example, the aforementioned “surprise medical bill,” where an out-of-network provider or service was involved in what would otherwise be in-network care, and you had no idea. Depending on your insurer’s terms for out-of-network coverage, you could be on the hook for a lot of money, says the MBAA. And it would appear there isn’t a whole lot you can do about it ― except not get sick.

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