What is an Out-of-Network Medical Bill?

Patients with health insurance generally expect that all of their hospital bills will be covered by insurance. However, a growing number of patients are finding that they end up being hit with a surprise out-of-network medical bill, even when treated at a hospital in their insurance plan’s network.

This is because even if you are treated at a hospital that is considered “in-network”—that is, one that belongs to a network covered by your health insurance plan—some of the doctors that may treat you are actually considered “out-of-network,” leaving patients with a surprise out-of-network medical bill that can be considerable.

One such patient is Margo A., a New Jersey resident interviewed by nj.com. Margo went to the doctor after suffering from shortness of breath that was serious enough to make her pass out more than once.

Though she went to a Tier 1 doctor, covered by her health insurance, she ended up being seen by a Tier 2 doctor, whose only role was telling her the results of her EKG test. The doctor recommended a procedure, but Margo declined, and was eventually discharged. A few months later, Margo claims she received a bill for $118 for the treatment from the Tier 2 doctor who gave her the EKG results.

Margo took issue with this egregious out-of-network medical bill. “If I am lying in a hospital bed and a strange doctor steps in and talks to me or gives an ‘inpatient consultation’ as it says on the bill, am I supposed to ask him, “Tier 1 or Tier 2?”

Margo is far from the only patient to be hit with a surprise out-of-network medical bill. Around 168,000 patients in New Jersey alone are hit with these kinds of bills, which cost $2,500 on average in that state, amounting to $420 million total per year.

The average out-of-network medical bill varies based on location. According to the Yale study, which covered millions of emergency room visits all across the 50 states, some places had significant out-of-network medical bill fees. Others had next to none, which researchers said indicated that this issue is solvable.

According to a study from the Yale School of Public Health and the Yale School of Management, the average out-of-network medical bill amounts to more than $622, a sum that can cause serious problems for some patients. Others are hit with an even larger out-of-network medical bill of thousands of dollars, which can be financially crippling. One patient was left facing a terrifying surprise out-of-network medical bill of over $19,600, the study noted.

While you may not have heard of out-of-network medical bill practices, it is quite common. In fact, it affects around 22 percent of all emergency room patients.

Patients may not know about this out-of-network medical bill for quite some time. In many cases, patients are often left unaware of this situation until after they have been treated by the out-of-network doctor and subsequently discharged from the hospital.

An out-of-network medical bill can still be partially covered by insurance companies, but at an out-of-network rate rather, much lower than what patients expect from a hospital covered by their health insurance. The patient is left to pay for far more, especially given that out-of-network doctors are usually paid significantly more than those that are in-network. Indeed, out-of-network doctors are, on average, paid 2.7 times more than in-network doctors.

If you were hit with a surprise out-of-network medical bill after being treated at an in-network hospital, you may be able to pursue a lawsuit for compensation.

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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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