If you thoroughly understand every twist and turn of your health insurance, you’re one of a rare minority in America. Insurance plans have become so complex it’s hard to tell when you might be stepping outside your network’s coverage.
When you are recovering from a medical procedure is not a good time to learn. Unexpected fees might add to the misery. The problem is huge. Nearly a third of insured Americans who have financial difficulties can blame part of the problem on medical bills they were not anticipating, according to a survey conducted by the Kaiser Family Foundation.
Some 70 percent of those who received unexpected bills didn’t understand that they were receiving services outside their insurance parameters. Problems often occur when there is a hospitalization in which a number of health professionals are involved. Payment guaranteed to your primary care physician often does not extend to emergency care doctors, anesthesiologists, radiologists and others who provide services.
A New York study in 2011 showed that the average cost of out-of-network services was $7,000. Often, medical costs are accrued in an emergency, so it is not likely the patient will be able to ask if those who take over his/her care are on their covered network. They are at the mercy of the system.
How to protect yourself
If you know you are being hospitalized in advance, call the hospital and try to determine who will be involved in your care and if they are part of your network. It isn’t foolproof, since the hospital may not know in advance which individual in a group of experts will take care of you. Also, ask that necessary tests done outside the hospital be sent to network providers.
Call your insurance carrier
If you’ve made those efforts and they don’t fully protect you from unexpected bills, the first thing you should do is call your insurance carrier and tell them the circumstances. Some employer-sponsored plans have policies that consider charges that were made without the patient’s understanding, particularly if they occur during an emergency. Your insurance company may be willing to negotiate with the providers for a lower charge.
Consumer protection agency
See if your state has a consumer protection agency that deals with medical payment issues. At least 10 states do have a program that will help consumers who are hit with unexpected medical charges.
Changing the laws
Experts who have made in-depth studies of the problem say that it will take changes to several laws, usually at the state level, to address the issue. New York has taken steps to protect patients in such instances. Its’ law does not eliminate the fees, but requires the insurance carrier and providers to negotiate.
As the scope of the problem grows, it is likely that resolutions will be sought. In the meanwhile, the majority of patients who are billed for out-of-network services have little recourse except to pay the bills.