Out-of-Network Providers at Hospitals Can Unexpectedly Bill Patients
Patients who visit an in-network hospital still could face thousands of dollars in out-of-pocket costs because of hospital practices that allow patients to be treated unknowingly by out-of-network providers, the New York Times reports.
According to health policy experts, hospitals commonly employ doctors who work for the hospitals and are included in the hospital's network. However, they also sometimes allow providers who are not considered in the hospital's network to work in the facility. Those out-of-network providers are allowed to charge patients for the balance of the bill that was not covered by their insurance, a practice known as "balance billing."
According to the Times, patients can be billed for those providers' services without ever knowing they were involved in their care. For example, a doctor can send patient X-rays to an out-of-network radiologist or their tissue to an out-of-network pathologist. Further, those who undergo surgery using an in-network surgeon could be charged by an out-of-network anesthesiologist or assistant surgeon.
Although some states limit the amount out-of-network providers can charge beyond what insurance has covered, there are no federal rules -- including under the Affordable Care Act -- that prohibit balance billing. However, the ACA does limit annual out-of-pocket expenses for in-network care at $6,350 for an individual and $12,700 for a family. It also offers some protections to individuals who seek emergency care by capping insurer copayments and co-insurance for emergency services at the amount it/the insurer would charge for in-network providers. Insurers must also pay out-of-network emergency providers according to a standard schedule.
Gerard Anderson -- director of the Center for Hospital Finance and Management at the Johns Hopkins University Bloomberg School of Public Health -- said about the only thing patients can do to avoid those out-of-network charges "is to go to a hospital where the [doctors] are all hospital employees."
Cheryl Fish-Parcham, deputy director of health policy at Families USA, and other experts recommend patients consult with their insurer to ensure it paid the correct amount and check state laws to see if there are any additional protections against balance billing (Siegel Bernard, New York Times, 10/18).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.