An increasing number of insured patients are stunned when they receive humongous bills from hospital emergency rooms and “contracted” physicians that are out of their insurance network.
Jon Hagey was very fortunate to have survived a serious bicycle accident last year. But when the bill for his visit to the ER at Katella Hospital in Los Alamitos, California, arrived, he was plunged back into shock.
“I was in the ER for a couple of hours, and I saw a doctor for about 15 or 20 minutes,” Hagey told Healthline. “I had X-rays on my chest and hand. I had two broken bones in my hand, and my chest was bruised. They fitted me for a soft cast on my hand. Then the bills started pouring in.”
Hagey’s bill from the hospital and a physician group totaled more than $5,000. Although he had insurance, he discovered that the hospital and the physician group were both out-of-network. His insurance did eventually pay a portion of the ER bill, but it was a fairly small amount, and a year after the accident, Hagey is still trying to whittle down his bill.
Recalling his reaction to the huge bill, Hagey said, “Am I supposed to call you to see if you are in-network? What if it was a life and death situation? This is insane. Once you pay the copay you think that is all you owe.”
Hagey disputed a $200 bill for an arm sling that he says he didn’t even receive. “They overruled my dispute. I said, ‘I’m not paying. Let it go to collection,’” said Hagey.
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Dr. Martha Wittenberg was also shocked when she received a huge bill after she had surgery to repair her hamstring several years ago. The orthopedic surgeon and anesthesiologist were in-network, and she paid the contracted rate for their services.
“It turned out the surgery center was not in-network. I didn’t even think to ask about this beforehand. Because of this, my insurance informed me after the fact that it was my responsibility to pay the facility fee, which was $30,000. I couldn’t believe it,” Wittenberg told Healthline.
Wittenberg was very fortunate. “They were nice enough to write it off because none of it was covered by insurance. After I received the explanation of benefits (EOB) from my insurance, I waited to get a bill from the surgical center. When it never came, I eventually called them. The woman I talked to in billing just said, ‘We simply wrote if off since you hadn’t met your deductible.’ I didn’t ask any questions; I was just thankful not to pay,” said Wittenberg.
Meanwhile, Hagey enlisted the services of Roanoke, Virginia-based Medical Recovery Services to battle on his behalf. The company helped him collect a payment from his insurer for a portion of the physician group’s bill. He sent the check to his insurance company, but when Hagey asked the insurance company to negotiate, “They said they can’t negotiate until they see the EOB … I sent it off to them. I’m sick of dealing with it. I had very stellar credit going into this. It will be a ding on my credit.”
Pat Palmer, founder and CEO of Medical Recovery Services, told Healthline that in the past year and a half, she’s seen an increase in hospital ERs using the services of “contracted physicians” or “traveling docs,” as well as outside labs and radiology services. These doctors and services are contracted by the hospital, but they are out of a patient’s insurance network.
“You assume, when you go to an in-network hospital, that everyone treating you is in-network. That’s not true. If you go to an ER, you sign admission forms. There is a tiny paragraph somewhere among the millions of sentences that says, ‘We may use outside doctors that are not part of your network and you are responsible.’ I’ve never seen that upheld in court, because you are not given details specifically on those doctors. If you don’t dispute it, you will automatically get that full bill from the anesthesiologist or surgeon. They’ll say, ‘I wasn’t in your network,’” said Palmer.
Many hospitals may have a contracting doctor on staff who does take your insurance, but the hospital may not use that doctor. “Maybe he wasn’t available that day or they had three to choose from and they just picked one. They are not doing cost-saving measures to use an in-network doctor, if there is one, and the patient isn’t even being notified,” Palmer said.
So what can you do if you lack the time, energy, or know-how and want to whittle down an astronomical medical bill?
Palmer advised patients to inform the ER personnel, and write on the admission form, that you want to be notified of any provider that is not part of your insurance program, or not in-network.
When negotiating with the provider, inform them that you never engaged their services directly; someone else engaged their services on your behalf, said Palmer. “Unless they have a signed document from you that you are agreeing to pay them anything they asked for, you want the bill adjusted to what the insurance is allowing,” said Palmer.
“Tell the provider, ‘If we can’t work on an agreement or come to a resolution on this bill, I will ask my insurance company to retract any money paid and to pay the person they are contracted with, which is me, the patient,’” said Palmer.
A lot of providers will work with you to come to an agreement, because they have already received some money from the insurance company. “There’s no guarantee they are getting a dollar from you when you’re mad, and they would rather keep what they have,” said Palmer.
Palmer said it is also helpful to contact the hospital and tell them, “I came to your facility in good faith that you were participating, and you chose on my behalf to use somebody who was not participating. I want a list of the surgeons who participate with you, because you were obligated to use cost-saving measures in any treatment you did for me in this facility.”
The hospital has influence with contracted doctors and may negotiate with them on your behalf, said Palmer.
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Finally, if you decide to hire a professional advocacy firm to work on your behalf, Palmer said to make sure they are very knowledgeable about the rules and regulations for billing and insurance reimbursement.
Michelle Katz, a healthcare consumer advocate in Los Angeles who helps consumers via healthcarehacker.org, advised patients to tell ER personnel that they don‘t want to sign any forms they don’t understand. “Tell them you want to take the document home and have an attorney review it. Write on the consent form, ‘I do not understand this form,’” said Katz.
Have a friend or relative with you to advocate on your behalf. Document the names of the doctors who came in to treat you. If possible, ask each person who treated you, What’s your name? Can I have your business card?
Before leaving the ER, Katz advised, you should insist on receiving a printout of the itemized bill. Check carefully to see if there are any mistakes on the bill. Are there charges for any tests you did not receive? Ask to go through the charges line by line with someone at the hospital before you pay the bill, Katz recommended.
Make sure your name and insurance card identification number have been entered accurately, and that the tests and procedures performed have been recorded correctly. Is more than one doctor billing you for reading the same report? “If you can find mistakes, you have better negotiating power, and you probably will find mistakes,” said Katz.
Finally, Katz said to send polite emails informing the billing staff that you want to pay the bill, but that you can’t afford to pay at this time.
Derek J. Fitteron, founder and CEO of Medical Cost Advocate in Wyckoff, New Jersey, told Healthline that patients have the right to appeal charges, especially for procedures that weren’t medically necessary or were not received. “The hospital will check the records and the doctors’ notes to determine what was actually done,” he said. Fitteron cautioned that appeals are time-consuming.
Firms like Medical Cost Advocate use data to look at the market value of a procedure in relation to other hospitals in an area, to help patients negotiate reduced charges.
Although in an emergency patients may be taken to the nearest hospital and that hospital may not be in-network, Fitteron said in certain states, such as New York, consumers still end up paying an in-network rate.
“Insurance has realized it is not the consumer’s fault. In that case, the insurance company takes the burden because the insurance company will be billed out-of-network, but will reimburse the patient as if they are in-network,” he said.
In the end it comes down to being proactive. “The bottom line is, patients need to be incredibly careful when choosing their insurance. They need to carefully read the small print about what is covered and what isn’t,” Wittenberg said. “Beyond that, they should also check in advance with their insurance to see which hospitals, surgical centers, outpatient procedures, and ERs are covered.”
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Photo of Michelle Katz courtesy of Elle Toussi