Out-of-Network Medical Bills Surprise Patients at In-Network Facilities

Logic dictates that if you go to a hospital emergency room at a facility within your insurance plan that you will avoid out-of-network medical bills. Not necessarily, however, says a new study from the Yale School of Public Health and the Yale School of Management.

Nearly a quarter of all emergency room patients end up with a surprise medical bill that averages more than $622, according to the study. The patient usually ends up responsible for that balance due unless their insurance plan is convinced to cover it.

Some surprise out-of-network medical bills can be even higher. While conducting their research of more than two million emergency room visits, researchers found one patient who was looking at $19,600 in out-of-network costs at an in-network facility.

When doctors are in-network with an insurance company, the physicians accept a negotiated rate for their services when they treat covered patients. The Yale study showed that out-of-network emergency room physicians received 2.7 times the pay that in-network doctors earned for the identical services rendered.

“Our results are deeply troubling,” authors Zack Cooper and Fiona Scott Morton wrote in an article for the New England Journal of Medicine. They said nearly half of all Americans couldn’t afford a $400 surprise medical bill without selling assets or borrowing money.

The issue appears to be that emergency room doctors negotiate contracts independently with insurance companies. This happens even within medical practices. For instance, doctors that work in the same ear, nose and throat office might not all accept the same insurance plans if they negotiate individual contracts with insurance companies rather than negotiate as a group.

Out-of-Network Medical Bills More Likely in Some Areas

Yale researchers found that out-of-network medical bills appear more likely based on geographical location.

“In McAllen, Texas and St. Petersburg, Florida, surprise-billing rates were 89% and 62% respectively,” Cooper and Morton wrote in their article. “In contrast, in Boulder, Colorado and South Bend, Indiana, the surprise-billing rate was near zero, suggesting that surprise billing is a solvable problem.”

The state of New York has passed a law that prohibits out-of-network doctors from balance billing patients who are treated by them at an in-network location. Cooper and Morton point out in their article that the law does require quite a bit of paperwork to get it upheld in each situation.

The Yale study found patients have nearly a 25 percent chance that an emergency room doctor at an in-network facility is actually an out-of-network provider.

In addition, specialists that you might need as part of your emergency room treatment might actually be employed by outside companies, not by the hospital itself. Radiologists, anesthesiologists, pulmonologists and infectious disease specialists might all work for different companies, but be on staff at the hospital as well.

The companies that actually employ these specialists could be the source of out-of-network medical bills.

If you have received a surprise out-of-network medical bill from a physician that saw you at an in-network hospital, you could be eligible for compensation.

Join a Free Surprise Medical Bills Class Action Lawsuit Investigation

If you received a bill from an out-of-network doctor after being treated at an in-network hospital, you may qualify to file a surprise medical bill lawsuit or class action lawsuit. It’s absolutely free to take part in an initial consultation, so act now!

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