Stories from You: Out of Network? Out of Luck.

Daniela Nuñez
Social Media Program Manager

Wednesday, February 10th, 2016

When dealing with something as serious as surgery, it’s understandable to want to know exactly what you’re getting yourself into and how much it will cost. When operation day comes, however, you ultimately have to rely on your doctors to make the decisions that are best for your health. But what happens when these decisions mean bringing in a provider who is out of network? For Michelle, this meant shock in the form a large, mysterious bill.

More than five months after my hernia surgery, we get a notice from my insurance company that a surgical assistant who helped at my surgery was asking over $6,000 in fees, and my insurance company denied the assistant as being out-of-network and unnecessary to the surgery. The fees were twice what the surgeon demanded. I never met this assistant, he was never listed on any of the initial or post paperwork for the surgery, and finding out five months later didn't make me thrilled. A week later, I got a letter from a collection company to pressure my insurance company to pay the surgical assistant. I've filed an appeal, but I have to admit that I don't know who is more at fault. I had no idea about this practice until I started researching it, and what I've found about the practice is startling and maddening.

After we reached out to learn more, Michelle gave us an update: “My insurance company reversed their decision in the appeal, and is paying the bill. I was never able to get in contact with the surgeon or the assistant, and I suspect they stonewalled me.”

Patients going into surgery should be notified in advance if any of their doctors, including assistants, will be out-of-network rather than finding out through a surprise bill on their doorstep. That way after surgery they can focus on healing, not fighting off surprise bills. With health insurance, you deserve to get what you’ve paid for. Join our campaign to help us win protections against surprise medical bills, and sign our national petition today. And if you live in Georgia, we are working with Georgia Watch and Georgians for a Healthy Future to make surprise medical bill protections a legislative priority. Share your story today.

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One response to “Stories from You: Out of Network? Out of Luck.”

  1. JT says:

    I think it is very important to understand that there is no protection in any policy for out of network providers and even Emergency care balance billing, no matter what you think your policy says. Our policy says “we’ll pay for emergency care as if it is in network”. Sound great doesn’t it…haha…fool the consumer. If you have to be transported by an ambulance (and few are in network, or you don’t take a list around with you on who to call), and you are taken to an out of network hospital…your insurance company will process it as in-network, paying their customary charges…but the providers will then stick you with the balance (they don’t care how your insurance company pays as they aren’t in network remember)…and worse…if you have an out of network limit, this balance bill doesn’t go toward that limit, because the insurance company said they paid it as “in network”. So let’s say you get a emergency hospital bill for $75,000 (not uncommon), and your insurance company decides $10,000 is innetwork customary charges, you are paying $65,000. Oh, but you thought you had a cap on out of network charges…no..this balance bill of $65,000 doesn’t apply as out of network. It is the most legal scam around. So everyone needs to know that all insurance policies expose you to this catastrophic risk exposure. Best then to go to a travel insurance company…and just google it, and buy a supplemental policy to cover some of this emergency cost exposure if you are away from your home, but this does nothing for the out of network issues close to your home.. So bottom line ….no way out. BTW…this did happen to us on a ambulance…ambulance was out of network (cuz most are), and they billed us $1,500. Insurance company (Big one that starts with a HU…), paid customary charges of $495, and we got balance billed $1,015. And this $1,015 did not accumulate toward our out of network deductible, so was money to the wind.

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