Unexpected Medical Bill Can Surprise Even an Insured Patient

Patients who thought they were getting in-network medical care may be surprised to get a hefty unexpected medical bill from an out-of-network provider.

For insurance purposes, facilities and providers may be treated separately. Doctors don’t necessarily participate in the same networks as the hospitals and clinics where they work. An out-of-network doctor may work through an in-network hospital or clinic, or vice-versa. The patient’s out-of-pocket costs tend to be much higher when billed at the out-of-network rate.

Patients who need only simple and straightforward care may not face too much difficulty confirming that both their provider and facility are in-network. The trouble comes when a patient needs more than one provider for a single condition.

Take surgery, for example. A patient may make a point of selecting both a surgeon and a hospital that is in their insurance plan’s network. But other care providers, such as anesthesiologists, radiologists or pathologists, will also be involved in that surgery, and those providers may not participate in the patient’s network.

A similar situation can happen when patients seek out emergency care. According to one study by Yale University, patients who do not purposely select an in-network emergency room and an in-network doctor have an almost 1 in 4 chance of being seen by an out-of-network doctor.

In other contexts, out-of-network specialists may be brought in solely for consultation. And some entire care units may not participate in the same networks as the hospitals in which they’re housed.

Patients may not have the foresight – or the opportunity – to designate all in-network providers prior to care. Their insurer would then pay the out-of-network provider at the lower out-of-network rate, and the patient then gets the unpleasant surprise that they are being billed for the balance. This practice is sometimes referred to as “balance billing.”

Sometimes the reverse can happen. A patient may choose the in-network provider of her choice, only to find out when the bill arrives that the provider works at an out-of-network facility. That situation can leave the patient on the hook for facility charges that her insurer will not cover.

Can a Patient Avoid an Unexpected Medical Bill?

Avoiding an unexpected medical bill isn’t as easy as patients might like it to be. With some exceptions, providers and health plans tend not to provide cost estimates before the patient undergoes a potentially expensive procedure.

Prior to seeking treatment, patients may get the information they need by specifically inquiring about the role of out-of-network providers in their care to try and avoid receiving an unexpected medical bill.

Claims consultants and patient advocacy organizations are available to help patients check their bills for incorrect charges. They often charge a fee for their consultation, however.

The insurance companies themselves are in a position to help their insureds make more informed decisions about their care. They can offer insureds a clear disclosure of exactly what providers and facilities are in- or out-of-network. They can also influence facilities to make in-network providers available and to disclose which of their care providers are in- or out-of-network.

Attorneys are now investigating potential claims from insured patients who ended up stuck with an unexpected medical bill. Qualifying persons who were billed for seeing an out-of-network physician at an in-network facility may be eligible for a free legal consultation.

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!

Get a Free Case Evaluation Now