If You See an Out-of-Network Provider, Are You Stuck With the Bill?

Well, it depends on a few factors.

If you choose to see a medical provider in his/her office and that provider is not in your network, then you are considered a self-pay patient and you are responsible for the bill. It is the patient’s responsibility to know what providers are in their network, so if you see an out-of-network provider you pay the costs. Here are a few common scenarios any my advice for how to handle them.

Surprise Bills From «In-Network» Hospitals

If you visit a hospital emergency room, and the hospital is in network, there is a possibility that the doctor overseeing your care is not in-network with your plan. That’s because many hospitals outsource the physician staffing of the ER. That means that the company that employs those doctors is responsible for the networks they participate in, not the hospital. You need to pay very close attention to these charges because accurate processing and payment of them often requires repeated and time-consuming conversations and follow up with your insurance company in order to have them paid appropriately. There is often an argument to be made to have the out-of-network charges covered as in-network but the determination is not automatic and requires considerable advocacy on behalf of the patient.

When «In-Network» Doctors Use «Out-Of-Network» Labs

Be aware that should you see an in-network provider, and that provider utilizes the services of a lab that’s out-of-network, you could be responsible for those charges. Determining in advance which labs are in your network and requesting that your doctor use those in-network facilities could save you a lot of time and money.

Negotiating «Out-Of-Network» Medical Bills

If your plan offers out-of-network benefits, the charges for any out-of-network services can be presented to your insurance company for payment. However the insurance company determines the allowed amounts for those charges and usually there will be a deductible to satisfy before the insurance will pay anything for the services. Keep in mind that the “charged” amount is NOT necessarily the same as the “allowed” amount. And it is only the “allowed” amount that is the amount that would be considered.

Help On The Way?

In some states, there is a law to help with these types of overcharges. It’s called the Surprise Medical Bill law and it states that if you enter the hospital and are seen by an out-of-network provider, that provider must provide you with advance notification of their being out-of-network and you must sign a document stating you have been made aware of this. If neither of these actions occurs, you are not responsible to pay the charges. The charges, in essence, are considered “surprise” bills.

Hiring a Medical Bill Claims Advocate Can Simplify The Process

In any case, thorough review of the charges could uncover billing errors that could reduce your financial responsibility. In these instances, it could be a good idea to enlist the services of a medical claims advocate who would be well-equipped to handle the matter and ensure the accuracy of the charges. Advocates are also usually adept at negotiating reductions in fees even when the charges are correct.

For more information on the validity of medical bills, reach out to us for more details on how to control these types of medical costs.