“Don’t get caught with ‘out-of-network’ bills: Be Prepared”

Most health insurance plans offer different coverage between “in-network” and “out-of-network” care.  Many of us have been caught with surprise bills for “out-of-network” services when we were under the impression that the facility we were using, and therefore all the services rendered in that facility, were “in-network” and covered according to the terms of that coverage.

The most important advice for avoiding these surprises, as with many things we’ve learned the hard way, is BE PREPARED!

First – familiarize yourself with your own health insurance coverage rules.  They are easily available, often on-line.  Be sure to read them carefully. Additionally, there are a number of helpful resources that can enhance your understanding  of your own health care plan and which may assist you in navigating what is often a confusing path. If you’re preparing for a scheduled procedure of any kind, it makes sense to check them out.  I found one particularly helpful, although there are a number of others: fairhealthconsumer.org  (under Health Care Resources)

Second – check with the facility and make sure you are being admitted to a hospital/facility in your plan.  Don’t assume that someone else will make sure you’re staying “in-network,” and don’t listen to hospital staff that tell you they’re “sure your insurance will cover this procedure or facility.” Sometimes they know, but too often they don’t.  Anyway, the meaning of the word “covered” is not consistent.  And, unless someone is confusing you intentionally (which is not common, or easily proven), you are not relieved of your responsibility to actually know the answer.  Best to get your plan to “pre-qualify” the procedure and the person performing the procedure.

Third – you also need to check that your surgeons are covered, and that ALL of your providers involved in your treatment while in the facility and during your recovery are also covered. This includes assisting surgeons, anesthesiologists, radiologists, and other kinds of specialists.

What you can do is communicate and ask for only “in-network” providers. You can insist on it, but remember, this may cost you some control over your procedure elsewhere, so be ready to make adjustments as necessary. For example, some surgeons will say they like to work with someone in particular, and when you check if this person is “in-network,” you find out that she’s not. What do you do?  You explain you’d like her to pick someone “in-network.”  Make sure your request for only “in-network” providers is included in your records and attached to any forms you sign.

It’s usually emergencies that can get complicated. Most plans cover for emergencies because double-checking with your insurance first is impractical, to say the least. Then, when the emergency has passed, they move you to an “in-network” facility. But not all “out-of-network” emergencies are covered.  Only true emergencies – meaning, emergencies that are defined by the PPACA that pass muster using the “Prudent Layperson Standard” (in short, if an average person thinks it’s genuinely an emergency with severe pain and sufficient severity).  But, you can ask your insurer to tell you what constitutes an emergency as far as they’re concerned.

If you’ve already gotten one of these “surprise bills,” you can contact the provider and try to negotiate the bill down. But, understand that no one is obligated to do this for you. So, if you’re going to try to negotiate, do it right away. Don’t refuse to pay it and then try to negotiate. You know it won’t work that way!  Remember that even if you went “out-of-network” accidentally, no one has an obligation to feel responsible for your “misunderstanding.” The only way to avoid this is to responsibly prepare up-front and well in advance.

ALL READERS:  This blog is not, nor shall it be deemed to be, legal advice or counsel. This blog does not create an attorney-client relationship with any reader.  It is designed to encourage thoughtful consideration of important legal issues with the expectation that readers will seek professional advice from a licensed attorney.