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Are You Being Treated by a Subcontracted Doctor?

May 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medicare

A recent story from Dayton, Ohio, caught our attention, where according to news reports, some patients remain responsible for emergency room charges when a hospital happens to ‘subcontract’  doctors who may not accept health insurance at all. This adds another layer to the oftentimes confusing in network vs. out of network debate. In many cases, especially in an emergency situation, patients who visit a local hospital or facility may experience unexpected costs after they are cared for by a doctor who may not be ‘in their network’, even if the facility itself is listed as an in network provider. There’s been a lot of discussion whether this, which may seem deceptive, especially to those without specialized knowledge in the medical billing and health insurance field, is fair. In fact, state officials, like in New York, are  looking to pass legislation which mandates better transparency for out of network charges. Taking the time to understand your health insurance plan and what defines a covered provider or facility can save you hundreds if not thousands of dollars in non-covered charges.

It seems providers tend to respond to these scenarios in two ways: Some indicate they will change their policies to include more transparency while others claim to be bound by federal laws that do not allow them to reveal to patients whether an on-call doctor or a physician on shift will accept their insurance or not.

We find the second argument to be completely unacceptable at face value. In fact, it’s reasonable that consumer advocates would expect state regulators to crack down on these well documented examples of seemingly unfair provisions in delivering medical services. It’s not outside the realm of possibility that a patient facing bankruptcy after a bill like this would have a basis for legal appeal, especially as new legislation is introduced and passed. It’s vitally important that you discuss your options and ask questions before treatment to minimize impact to your financial future. How prepared are you in the event of an emergency room visit?

Beware of Balance Billing in Hospital Bills

May 12, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.

How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).

In- Network

Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.

Out-of-Network (OON)

There are two scenarios:

  • If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
  • If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.

When in doubt, check with a medical bill advocate.