A few months back, I had to take my wife to the emergency room. I have two hospitals within 5 minutes of me. Both are considered in network hospitals in our medical plan. I chose the closest of the two.
After being transferred to another in network hospital and a six day hospital stay, she was released from the hospital.
Within a month or so after, the medical bills started to roll in. I carefully reviewed them along with the Explanation of Benefits statements from the insurance company.
One doctor bill I received was denied for being an out of network provider. This came as quite a shock to me since I carefully chose an in network emergency room and hospital. However, through no fault of my own, I got an out of network bill because the doctor in the emergency room providing treatment for the in network hospital isn’t part of the network.
This is downright stupid to me.
After doing a little research, I discovered that getting surprise out of network medical bills is pretty common. Of course, it wasn’t very shocking to learn it’s a common practice. In fact, here’s a guy who had a heart attack and ended up owing $109,000 dollars.
Unfortunately, this practice is pretty unfair to policyholders but of course, it’s perfectly legal for insurance companies to do it for the most part.
It would be one thing had I chosen an out of network provider and gotten an out of network bill. However, I did what I was supposed to do and went to an in network provider.
Since I don’t feel I owe this bill, below are the steps I am going to take to deal with it. I can’t guarantee it will resolve my problem or yours if you have it. I’ll keep you posted.
But first, let’s go over why receiving an out of network bill is a problem.
The Problem with Out of Network Bills
When you receive medical treatment, after the insurance company decides if the medical treatment is covered under your policy and is medically necessary, they look to see whether the provider is an in or out of network provider.
The problem with out of network providers is that they are subject to a separate and often higher deductible. So even though we have met our health insurance in network deductible, we have to meet an entirely new out of network deductible before the insurance company will pay anything.
Since we haven’t met the out of network deductible, we owe the full amount of this doctor bill even though we have already met our in network deductible.
Here are the steps you should follow to avoid and tackle these out of network charges.
Step 1: Always use an in network provider
While it might seem obvious, the first step in avoiding problems with unexpected out of network medical bills is to only go to in network providers.
You should verify who is an in network provider by contacting your insurance company. Don’t rely on the provider to tell you. The provider doesn’t pay your benefits out. Your insurance company does. I’ve been given wrong information from numerous providers over the years.
Providers bill and insurance companies pay.
Unfortunately, it’s on you to find out. If you get billed by an out of network provider because you didn’t bother to check or because you personally wanted to use that provider, there isn’t much you can do about it.
Remember, networks can change too. Be especially careful if your health insurance company changes.
Check all your doctors and pharmacies before you use them. Think ahead. If there is an emergency due to an accident or health issue, know where you should go before an emergency happens.
In the case of my wife’s emergency room visit, we knew ahead of time that both hospitals were in network.
Step 2: Don’t pay the bill right away
Like all medical bills that are denied by the insurance company, you should always refuse to pay the bill until you find out for sure the insurance company is really denying it and you really owe it.
I can’t count the number of medical bills we have received over the years that the insurance company has initially denied only to pay later. I think it’s standard practice by the insurance companies to deny certain bills that they know with proper coding will be paid.
One time I remember getting a surgery pre-approved only to have them deny paying the anesthesiologist because I didn’t get the anesthesiologist pre-approved. Even though, it’s common sense that in order to have surgery, you NEED an anesthesiologist.
Initially denied, the insurance company eventually paid the anesthesiologist bill after I complained.
I think they deny these initial bills because they are hoping you will just pay the bill without challenging the decision. I’ve talked with lots of people who tell me they have done exactly that.
This just lets the insurance company off the hook for bills they owe.
With the high cost of health insurance premiums, you should never cave in so easily.
Don’t pay the bill until you know for sure you are indeed responsible for the amount.
Step 3: Dispute the decision of the insurance company in writing
Once you receive the Explanation of Benefits (EOB) from the insurance company, review it to see how they handled your provider’s claim.
If you need help understanding the EOB, contact the insurance company for help. In most cases, the insurance company will process your claim correctly and you’ll need to pay your share of the bill.
In our case, the EOB stated that the bill was denied because the provider used in the in network facility was an out of network provider.
I’ll let the insurance company know the circumstances in our situation in our written request and ask them to review it.
Hopefully, they will review it and pay the claim. If not, I’ll move on to the next step.
Step 4: Dispute the bill with the provider in writing
Next, contact the out of network provider in writing and let them know the situation. Advise them that you will not pay the bill because you went to an in network provider.
Let them know that you’ve contacted your insurance company to review the decision. Further, let them know they need to work with the hospital which was an in network provider and your insurance company to resolve their issue.
Step 5: File a complaint with the Department of Insurance and the Attorney General in your state
If you have no luck with the insurance company or the provider, file an complaint with your state’s Department of Insurance and a consumer complaint with your state’s attorney general.
Filing complaints like these will often get your situation resolved. But if not, the more people who file formal complaints will put this on the radar as an issue that needs to be solved.
Some states have already passed laws helping consumers getting unexpected out of network bills. While some of these laws have problems distinguishing between self insured and fully insured plans, at least it’s a start.
NOTE: If your health insurance is provided by your employer, also let your employer know about your issue.
Step 6: Contact the media
If your bill is large enough, contact your local news channels and let them know about your problem. If it’s completely outrageous they may be able to help.
The guy I mentioned above followed a similar strategy and got the $109,000 out of network bill eventually cut to $332.29.
Step 7: Refuse to pay the bill
If all else fails, then you can just refuse to pay the bill.
They can certainly put a mark on your credit report. They are hoping that other creditors you need to work with will force you to pay their bill even if you don’t really owe it.
The worse thing that could happen is that the provider could take you to court over the amount due.
Most people lose in court because they don’t defend themselves.
Defend yourself. Keep copies of all of your interactions with the insurance company, the provider and the state.
Make a judge decide if you have to.
Update on my wife’s surprise bill
The first thing that I did was contact the insurance company. The representative from the insurance company explained to me that the reason the bill was not paid was because we hadn’t reached my wife’s deductible.
However, we had already met my wife’s deductible. The explanation of benefits clearly showed we had.
After a lengthy discussion with her, she finally put me on hold and got another representative to take my call.
I explained the situation to the new representative who understood what she was looking at. She agreed that we had met our deductible. While this was indeed an out of network provider, they did pay it with in network benefits.
Only problem was that this was a balanced billing situation where the provider was charging the balance above the allowed amount.
She offered to have the claim re-processed and told me that should fix the problem.
After I spoke with the insurance company, I contacted the provider and let them know. In both cases, I wrote down the contact information of the people I spoke with.
The next step for me is to wait for a new explanation of benefits from the insurance company to see if the claim was processed correctly.
I’ll update this once I receive it to let you know.
Always question the insurance company and the provider when the insurance company denies claims. The insurance company is counting on you to absorb as much as they can transfer over to you.
When you don’t say anything when you have a valid claim, you only do them a favor.
Use the suggestions above to resolve your out of network bills when you went to an in network provider.
Have you received a surprise out of network bill from an in network provider? Let me know what happened in the comments how it worked out.
Also, let me know if you used any of my suggestions to help you out.
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