Protect yourself from surprise out-of-network medical bills

Avoid if possible—raise a stink if not

Published: October 03, 2014 08:00 PM

Getting medical care from a doctor, hospital, or lab outside of your plan's provider network can run up ruinous medical bills. But you can be blindsided by surprise out-of-network charges in emergency rooms or hospitals staffed with doctors who don't participate in the same plans the hospital accepts. Here are six ways to protect yourself.

  1. Understand your health insurance. OK, it’s not a fun read, but take the time to familiarize yourself with your health plan's rules. If your plan is a Health Maintenance Organization (HMO) or a Exclusive Provider Organization (EPO), you will not have any coverage for out of network care except for emergencies when you are outside the plan’s service area or for hard-to-find treatments for rare conditions. You should also find out if you need advance approval for tests, elective procedures, or specialist visits—even when you plan to go to an in-network doctor. Your plan’s Summary of Benefits and Coverage will have this information.
  2. Stay in network if you can. Network providers have agreed to accept the negotiated health plan price as payment in full. This is a big savings for you, compared to going out-of-network.  Even if you have a Preferred Provider Organization (PPO) or Point-of-Service (POS) plan that covers some out-of-network costs, there is no limit on the balance for which the doctor can bill you.
  3. Don’t rely solely on the health plan’s online provider directory to find in-network hospitals, doctors and labs. These directories can contain errors or become out-of-date. Call your health plan to confirm.
  4. If you are having surgery, tell the surgeon and hospital you want to use only providers that accept your insurance. It may not work, but it never hurts to try.
  5. If no network provider is available, complain. Health plans are legally required to maintain “adequate” networks of providers. If yours has not done this, ask the company to let you use an out-of-network provider at the in-network rate. If you don’t get a satisfactory answer, complain to your state insurance department.
  6. If you get a surprise bill, fight back. Ask the doctor to lower your bill and ask your insurance company to help you resolve the situation. If you have insurance through a large employer, ask your human resources department for help. If this doesn't work, complain to your state insurance department or Attorney General's office. Even if they can't help directly, your complaint will help them identify patterns of abusive billing practices. And finally, share your story with us here at Consumer Reports.

Good news for New Yorkers!

New York State residents will soon have the nation's strongest protections against surprise out-of-network bills, thanks to a new law that takes effect on April 1, 2015.

Instead of being left on their own to battle with bill collectors, consumers who get hit with surprise bills will hand them off to an independent arbitrator who will decide how much the insurer will have to pay the provider.

If you are interested in getting such a law passed in your state, here's more information.

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