Out of network provider at In Network Hospital (plan, doctor, surgery)
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Happy Monday! Mods please let me know if I placed this in the wrong forum. Just wondering if anyone else has experienced this and what I should've done or could've done differently.
I went to the emergency room in September due to severe abdominal pain. The hospital was in network so I assumed that my visit would be covered under the emergency care benefits provided by my insurer. I know, I shouldn't assume anything, lesson learned.
Fast forward to this morning, I received a bill for services provided by the nurse practitioner in the emergency room. He is an out of network provider. According to the hospital, he is a contractor and not subject to the in network rates negotiated between them and my insurer. Is there a way to find out if a provider is in network? Do most hospitals advise you that the doctors and nurse practitioners in the ER are considered to be contractors? I know when you're in pain, trying to figure out if a doctor is in network is the last thing on a person's mind but the sticker shock after the fact can be pretty painful.
Has anyone else experienced this? How did you handle it? What can you do in this situation?
Thanks for any feedback that you can offer. Have a wonderful day!
First, you need to know that even if you go to an in-network hospital not all providers at the hospital will be in-network with your insurance. There are certain groups of providers that intentionally choose not to contract so they can balance you bill you (ambulances, ER doctors, pathologists, certain kinds of specialists, etc.)
What most Plans do to try and rectify this problem, is if you did your part by going to an in-network hospital, but you were treated by an out of network provider at that hospital they will pay the out of network provider at the IN NETWORK BENEFIT LEVEL However, the out of network provider's fee will be limited to the USUAL AND CUSTOMARY AMOUNT. It is very rare that your insurance would pay an out of network provider at 100% of their BILLED CHARGE unless their billed charge is below the USUAL AND CUSTOMARY allowance.
In the example below let's pretend the out of network benefit level is 75% and the in-network benefit level is 90%.
For example:
Onet ER Doc charges $500.00
U and C Amount $400.00
In Network Benefit Level 90% $360.00
Your insurance pays $360.00
You owe $140. ($100.00 that exceeds U and C amount plus your 10%
coinsurance of $40.00.)
You should call your insurance to verify that the claim was paid at the in-network benefit level since you went to an in-network facility and had no control that a non-par provider was assigned to you in an EMERGECNY situation. If the claim was paid at the in-network benefit level verify if there was a usual and customary reduction. If you so -- you will be responsible for the difference between the billed charge and the U and C amount.
Most insurance companies use large databases such as Fair Health to determine what the usual and customary fee allowance in a specific geographic area is. You need to know the CPT code the provider billed, the billed charge, and the first three digits of the zip code where services were rendered. Fair Health U and C data is available online. You would also need to know what percentile your employer or insurer has elected to use to determine U and C rates (it is common to use anywhere from the 70th percentile to the 90th percentile).
First, you need to know that even if you go to an in-network hospital not all providers at the hospital will be in-network with your insurance. There are certain groups of providers that intentionally choose not to contract so they can balance you bill you (ambulances, ER doctors, pathologists, certain kinds of specialists, etc.)
What most Plans do to try and rectify this problem, is if you did your part by going to an in-network hospital, but you were treated by an out of network provider at that hospital they will pay the out of network provider at the IN NETWORK BENEFIT LEVEL However, the out of network provider's fee will be limited to the USUAL AND CUSTOMARY AMOUNT. It is very rare that your insurance would pay an out of network provider at 100% of their BILLED CHARGE unless their billed charge is below the USUAL AND CUSTOMARY allowance.
For example:
Onet ER Doc charges $500.00
U and C Amount $400.00
In Network Benefit Level 90% $360.00
Your insurance pays $360.00
You owe $140. ($100.00 that exceeds U and C amount plus your 10%
coinsurance of $40.00.)
You should call your insurance to verify that the claim was paid at the in-network benefit level since you went to an in-network facility and had no control that a non-par provider was assigned to you in an EMERGECNY situation. If the claim was paid at the in-network benefit level verify if there was a usual and customary reduction. If you so -- you will be responsible for the difference between the billed charge and the U and C amount.
Most insurance companies use large databases such as Fair Health to determine what the usual and customary fee allowance in a specific geographic area is. You need to know the CPT code the provider billed, the billed charge, and the first three digits of the zip code where services were rendered. Fair Health U and C data is available online. You would also need to know what percentile your employer or insurer has elected to use to determine U and C rates (it is common to use anywhere from the 70th percentile to the 90th percentile).
Thank you for the breakdown, Angie. I truly appreciate the clarification, this makes a lot of sense now.
I would suggest that before getting all worked up over this, check to see if your state has regulations prohibiting out of network charges for emergency services rendered through an in-network hospital. Way too many consumers allow themselves to be ripped off because they never took the time to learn the most basic about their protections.
Six states outright prohibit emergency rooms to charge out of network charges when a person is brought in.
Fifteen other states that has regulations that requires in-network billing for in-network emergency room care by out of network providers within an emergency room.
So, are you in one of those states? If so, use the regulations to fix it!
Note that this can also come up in non-emergency situations. For example (one we encountered): surgery with an in-network physician but the anesthesiologist is out-of-network. Patient should be advised of this in advance, but it's really on you to clarify/verify. In our case, the surgeon had strong opinions about the quality of the anesthesiologist and indicated that he would be unhappy if we insisted on a different, in-network person. Rock/hard-place.
Here is an article that discusses the issue, and lists those states (as of 11/2015) that have laws re consumer rights to not be ripped off by these blatant scams.
I had an orthopod, unbeknownest to me til the bill came, call in a "surgical assistant" to hold his hand. In researching the issue, it came clear to me that the "assistant" was his office partner's wife.
Having been on the board of a contractor company to a hospital, I can tell you it's not a scam. If the insurance company refuses to work with you and you cant include them in your network, that just screws the doctor and the patient.
I can't tell you how many of these things get pushed into bad debt.
Frankly, if it's an emergency, I don't think insurance companies have any business worrying about which network it is.
Oh, And be careful of the next thing they're doing. If they don't think that your visit was actually an emergency, blue cross is pretty much threatening to not pay anything.
Oh, And be careful of the next thing they're doing. If they don't think that your visit was actually an emergency, blue cross is pretty much threatening to not pay anything.
that's not quite accurate, there's a bit more nuance to it than you indicate:
"It defined inappropriate visits as any but those that “a prudent layperson, possessing an average knowledge of medicine and health,” would believe needed immediate treatment."
so if you've got chest pain, it's prudent to visit the ER. if it turns out to be GERD looks like you'll still be covered. there's no way a prudent layperson would, in most instances, be expected to differentiate.
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