Even with medical insurance, you may get surprise medical bills from out-of-network doctors

You have medical insurance, say, with Blue Cross.

You find yourself in a medical emergency like a heart attack. You go to a hospital that is covered by Blue Cross and undergo cardiac surgery, assuming your health plan will cover most of the costs.

Except it doesn’t.

That’s the nightmare that as many as 30% of Americans with private health insurance found themselves in last year, when they received a surprise medical bill from a doctor who had treated them but who is not in their insurance plan’s network. In some cases, the patient discovered even the hospital is not part of the network.

surprise medical billsMegan Thompson reports for PBS Newshour, June 26, 2016, on two such cases:

(1) 64-year-old Leigh Lehman of Hillsdale, NJ, needed a quintuple heart bypass. He made sure that both the Valley Hospital in Ridgewood and his surgeon accepted his Aetna Insurance, which Lehman gets through his employer, a small consulting company. A few weeks after the surgery, Lehman got a surprise bill in the mail for nearly $2,200 from a critical care doctor in the intensive care unit who did not accept Lehman’s insurance. The hospital and Aetna said there was nothing they could do, so Lehman dug into savings to pay it. He said, “It’s a little stressful. You’re trying to recover. It’s major surgery. I mean, I felt like I was hit by a truck.”

(2) Andrew Heymann, a New Jersey accountant, had health insurance through his employer from Anthem Blue Cross-Blue Shield. Two years ago, when he was helping a neighbor move, a large glass table shattered, and a shard of glass sliced deeply into Heymann’s left ankle. An ambulance took Heymann to the closest emergency room — at Hackensack University Medical Center – which he knew was in Anthem’s network. After a plastic surgeon sewed up Heymann’s leg, Heymann received a $6,000 “balance bill” from the surgeon who was not part of Anthem’s network.  Blue Cross covered about $860, but Heymann was stuck owing $5,000. Happily for Heymann, after 6 months of fighting his bill and appealing with his Anthem, his employer paid it off.

Chuck Bell, Programs Director at Consumers Union, the advocacy arm of Consumer Reports, says “We’ve received, literally, thousands of stories from consumers all over the country that are having this problem.”

The reasons for these surprise medical bills include:

  • Medical insurers increasingly are offering “narrow networks” — cheaper insurance plans that give patients fewer doctors to choose from. When patients go to a hospital or an emergency room, they inevitably run into physicians and providers that are out-of-network.
  • Physicians increasingly are opting out of insurance plans that they believe pay them too little, as insurance companies reduce payment, year after year, to the point that many insurance plans pay below what Medicare pays. A physician who is out of network is permitted to bill at a higher rate to the insurance company and patient.
  • Even hospitals charge insurance plans with out-of-network higher rates. Kevin Conlin, Chief Operating Officer of Horizon Blue Cross Blue Shield, New Jersey’s largest health insurer, estimates New Jersey’s insurers pay around $2 billion a year to cover out-of-network care.

The problem requires redress from state laws.

Four states — Illinois, Florida, New York and Connecticut — have already passed laws to protect patients against surprise medical bills. 28 states, including New Jersey, are considering such a bill.

state laws on surprise medical billsIn New Jersey, State Senator Joe Vitale is a sponsor of a bill that would:

  • Mandate most doctors to participate in same networks as the hospital.
  • Require doctors and hospitals to notify patients if they are not in network.
  • Ban doctors from balance billing.
  • Set up an arbitration system to press providers to defend their bills, and insurers to defend their rates.

But after years of negotiation, Vitale’s bill has gone nowhere because of competing interest groups.

Here’s the PBS Newshour video:

I suggest that, before we find ourselves in a medical emergency, we contact our medical insurance plans, doctors, and hospitals and find out their out-of-network providers.

Caveat emptor (buyer beware)!


18 responses to “Even with medical insurance, you may get surprise medical bills from out-of-network doctors

  1. Negotiate with your doctor direct on a cash basis… DON’T PAY THE MIDDLEMEN!

    Liked by 4 people

    • Amen, Cathy. I am part of a Christian sharing co-op called Samaritan Ministries and over the course of now over 9 years have yet to pay the asking price of any service provider or doctor, even though I get reimbursed. The system is corrupt and everybody in it knows that, so they all will settle when pressed. They understand that insurance companies and the government only pay what they decide to pay. One more example of the need to restore individual responsibility (which has for a long time longtime been abdicated) in all facets of modern life.

      Liked by 1 person

  2. This just happened to us. My husband required an extensive neck surgery, which our insurance covered at 100% (we have excellent insurance coverage, as we’re blessed with a “Cadillac” policy). The surgeon’s office got pre-approval, and since he’s in-network we figured all was well, especially since we used his private surgery center, which was also covered. A month later, we received a $2,700 bill from the anesthesiologist, who, apparently, does NOT accept our insurance. How does one protect against this? We thought we were covered!

    Now for a fight, which I don’t relish having.

    Caveat emptor, indeed.

    Liked by 2 people

    • It’s SO tempting to tell ’em,”Screw you-YOU were OFFERED payment and YOU rejected it.” But this is a “civilized society”,so we bite our lip and soldier on through the corrupt system…If I ever have a problem that requires expensive surgery,I’m telling ’em exactly what I have and don’t have to work with,and I’ll tell the Administrator of the Facility to make DOUBLE-damned sure everybody’s on board and get signatures agreeing to my payment plan-if they aren’t,tell ’em not to even show up-find someone ELSE who IS. There’s NO freakin’ reason the payment/billing stuff can’t be resolved BEFORE anyone walks into the operating room..When you’re admitted,all the information they NEED is right there. It’s NOT the Patient’s fault if they can’t take the time to look and see who’s supposed to pay them. THAT’S just Laziness.

      Liked by 2 people

      • Thank you! Good Lord, they have US signing documents to Kingdom Come…be nice if that was a two-way contract, huh? Well, I’ll pay, but I’ll pay on my own terms (we did get decent service, and my husband lived, thankfully), but that’s a lousy trick, and I’m happy to tell the anesthesiologist, the surgeon, the staff, and anyone else who cares to listen. 🙂

        Liked by 1 person

      • truckjunkie . . . I agree 100%. When the surgeon enlisted the help of an anesthesiologist, the surgeon’s office should have made sure that any doctor’s which were required for assisting them were also covered by the same insurance. It’s not like any of us go out and seek the assistance of an anesthesiologist . . . you just get whoever is assigned to your surgery. At least that is my experience. You meet the anesthesiologist just before surgery (which is a little late to ask if they are an “in-network provider”) and then you never see this doctor again.

        Liked by 1 person

  3. so “out of network” is the new catch phrase to screw over americans?
    damned if you do, damned if you don’t…..this obamination of health “care” was designed to fail the people…yet people applauded obama like he was a savior because they thought they were getting stuff for “free”
    nothing is free…

    Liked by 2 people

  4. The entire medical system in the USA is universally acknowledged as the very worst amongst the industrialised nations, as its profit-based structure does exactly what Marx predicted: it eventually removes all human values except for the commoditisation of a person as a source of income.

    Readers! Congress has superb, all-costs covered medical & hospital plans, paid for by tax-payers, i.e., the 90% who pay taxes that outsider 1%’er Broom Hilda don’t have to: their hundreds of millions are stashed overseas, in NON-TAXED bank accounts!!

    When they were caught they blamed my friend Dr Tom OBrien –their financial advisor at the time, who told them it was NOT a good idea– and put him through NINE NY Grand Juries in a vain effort to distract from their sins & crimes. ALL nine juries found Tom innocent; the dynamic duo of deceit then stepped in to bury the case under a 50 year Court ban on publication of anything.

    And voters trust these supremely slimey, satanic, demon-possessed murderers w/their vote for POTUS?!
    Just who is zooming who here?

    Liked by 2 people

    • those that make the laws profit from them: primo health insurance plans, raises, retirement, illegal stock trading that no one gets called out on, passing bills to hide their illegal activities, catered food, everything they do is written off in taxes, hedonist activities, armed guards, rigged elections, government cars to drive around in, etc.
      They live like royalty.
      the obvious conflict of interests are pathetic…becoming a member of the legislature isn’t about the democratic process, it’s about winning the lottery because they have set themselves and their families and friends up for life all on the taxpayer’s dime…these slimy backstabbers are the ultimate frauds and welfare queens.

      Liked by 2 people

    • “Medical Taylorism,” touted as an efficiency based system of maximizing health care services, is all about maximizing billable hours and is the reason why, if you visit the typical “world class” clinic for specialized care, you’ll spend hours sitting around waiting for two-minute screenings by one tech after another before seeing the doctor for ten minutes. The NE Journal of Med has an article under that title and rebuttal. In short, there’s no money in taking the time to treat you like a fellow human being and bigtime money in treating you like a component in a factory assembly line. These “scientific management” principles of maximizing profit over human values, including those of employees, characterizes all the professions and corporate strategies in America today. Understanding the details of these manipulative strategies lurking behind the smiley-faced and fancy-decor facade is enough by itself to make us sick.


      • But progressives do it while touting how “human” and caring they are.. just a public relations achievement, you see (the “narrative” is everything, reality is nothing… Thanks, Democrats!!).


  5. I never paid a lot of attention to the politics of medical care until Obama-don’t-care came onto the scene,but from what I can see,what we had before wasn’t that bad. I know prices went up,people were having a little trouble getting timely appointments,etc. but I really believe THAT could have been corrected by something less than trying to Socialize the Medical Care System.
    Besides,what better proof IS there that the ONE sure way to insure the failure of ANY idea is to put the GOVERNMENT in control of it.

    Liked by 1 person

  6. I feel for anyone caught in the current medical abyss. I am currently going through something similar. Having excellent coverage for 15 years, suddenly they denied a cat scan of my back for two troublesome places. Someone sitting at a desk thousands of miles away is making decisions they know nothing about. They said I couldn’t have the catscan until I had a sonagram. So we jumped through all their hoops in time and the sonagram proved me right, two problems were verified. The denied me again, after jumping through the hoops and proving there is a problem.
    I am not one to waste lots of time and money on medical tests, but they recently sent me a notice to remember getting a mammagram and colonoscopy, which I have no intention having. But still deny a tests that is truly needed. Go figure, idiots are in control. I pray they all lose their insurance and soon, while denying people and veterans medical care, while raising our rates yearly.

    Liked by 3 people

  7. Thanks, Democrats!! (Nice changes you foisted off on us there… )

    Liked by 2 people

  8. MOMOFIV you are so right. The term “out of network” is just another catch phrase for getting more money. You could also add the terms “co-pay”, “co-insurance” and “deductible.” We have been hit with all four of the above terms. Sorry Dr. E., as was pointed out, even if the institution you receive medical care from says your physician and the institution itself is in-network, there will inevitably be someone in the course of your treatment that is out-of-network. This is especially true with university medical centers / university medical schools / teaching hosptials. Most of these institutions have a core medical staff but all the other medical staff is very fluid going in and out of various parts of training in various departments as in — surgery or OB/GYN or Ortho, etc. For example the M.D. that sees you maybe employed by that institution as a Fellow in (you name the speciality) Department and therefore is not in-network. Another example would be a Chief Resident, which is a soon-to-be-M.D. but not quit there yet. Or a fourth year resident who is on-call in the ER. All of these could or could not be in-network even though your attending physician and the institution is in-network. As far as calling the administrative offices of the institution, FORGET IT! They will not know, they have no records to indicate yea or nay and low-paid clerical staff that answers the phone have been told nothing on how to handle the questions other than “don’t be rude, don’t say anything that is inflamatory, comment on nothing, commit to nothing and end with a smile in your voice!” AND above all else do not bother us with these silly calls!!!!! Oh I could write a book on this subject, but won’t. My answer is to never ever have medical treatment unless it is for a broken bone, the flu or something that can be fixed immediately and everything heals and all is well. Anything that involves the “miracle of modern medicine” just let nature take its course. We all need to remember that there are worse things than death and I quote — “…..no greater love hath a any man than to give his life for his brother…….” I am a firm believer — yes this is based on experience — that God Almighty did not intend for his creation to ruin their lives, ruin their famly’s lives, ruin their financial lives, or be forever in debt to the medical/industrial complex, just so modern medicine can prove they are capable of extending a human life at any cost. May the Lord have mercy.

    PS: Controlling the medical institutions and pharmacies was a major way that Hitler made sure the German people were under his control. Sounds like the United States of America to me.

    Liked by 2 people

  9. Doctor, interesting that there is two down votes for every entry. Looks like we have been hijacked from the opposition.
    Can’t imagine anyone being happy with what has happened to our medical coverage.
    The trolls are busy little people.


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