Linda Weeks worked for years in human resources jobs, so when her husband, Thomas, needed hand surgery last year, she double-checked that the surgeon and hospital were both in their health insurance provider network.
“The hospital verified that they were covered,” she recalls. “They actually told me what my out-of-pocket cost would be, and I paid that up front.”
And sure enough, the Weeks, of Loganville, Ga., never received another bill from the surgeon or the hospital. But a few months later they got a bill for $1,264 from the anesthesiologist, whom they met once, on the day of the surgery, and had no part in selecting.
Linda learned that the hospital had an exclusive contract with an outside anesthesiology practice that didn’t take their health insurance, something they hadn’t bothered to mention beforehand. Their health plan paid just $152 of the bill, which it said was all it owed for out-of-network care based on the “usual and customary” fee for the type of anesthesia Tom received.
The Weeks are still trying to get the anesthesiology practice, part of a national chain, to reduce the bill to what they consider a reasonable amount. Along the way they have appealed to the hospital, their insurance company, and the state’s insurance regulators, all of whom have said it’s not their problem.
Not an isolated incident
This happens to people a lot. A 2015 Consumer Reports national survey found that one-third of respondents reported that they’d received surprise bills for which their health insurance paid less than expected. Of those bills, about one in four were from doctors whom they didn’t expect would bill them.
Because out-of-network doctors don’t have a contract with your insurance company, they can charge you whatever they want—and aggressively go after you to pay it.
You’re most at risk for a surprise bill when you go to a hospital emergency department, or when the hospital assigns you an “ologist, like an anesthesiologist, radiologist, or pathologist,” says Chuck Bell, who’s overseeing a campaign to stop surprise bills at Consumer Reports. “Unfortunately, physicians and hospitals don’t necessarily see it as their job to make sure all services you get are in-network.”
This happens even when patients make sure they stay within their insurance network. A recent study of more than 2 million emergency room visits from a large insurer claims database found that more than 99 percent of claims were to in-network hospitals, but 22 percent of the visits still involved out-of-network emergency room doctors.
And those out-of-network doctors really cleaned up: They charged nearly eight times the standard Medicare rate for their services, compared with the average in-network payment of a still-generous three times the Medicare rate. One unlucky patient ended up with an out-of-network bill of $19,603.50.
How to prevent surprise bills
Unfortunately, there’s not much you can do pre-emptively, says Bell, beyond doing your best to stay within your health plan’s network. “The important thing is to fight the unfair bills if you get them,” he says.
Start by appealing to your health insurance company and the provider who sent you the bill. If you get no satisfaction, “call your state insurance department, because there may be laws that protect you,” Bell advises. “And even if there aren’t, they might be able to mediate on your behalf.”
Some states also have government-funded or nonprofit agencies that can help. Here are links to the resources in your state.
These five states have recently enacted laws that protect patients from having to pay outrageous surprise bills: California, Connecticut, Florida, Illinois (for emergency room care only), and New York. Some states have partial protection, and still others are considering legislation.
Here’s how to find out what’s going on in your state.
Nancy Metcalf is an award-winning independent journalist specializing in health topics. A senior writer and editor for Consumer Reports for more than 25 years, she is a nationally recognized expert on health insurance and health reform.