Medical insurance booby traps

When Austin, Texas resident, Bill (right), went to the emergency room for an injury, he did the right thing. He called his insurance company and confirmed that the hospital was in-network. As he told our Cover America Tour, after receiving the bill, he discovered that the doctor who treated him was out of network. Andrea, from Murphy, Texas, was also faced with a large bill after her infant son was treated in the neonatal intensive care unit by a physician who, it was later revealed, did not participate in her plan. Anyone can fall victim to our fragmented health delivery system. It's happened to me more than once.

I'd like to consider myself a savvy health care consumer—I run a medical practice and handle all my family’s health insurance claims. But when I went for an annual mammogram and received a bill for the radiologist’s fee a few weeks later, I learned that the radiologists had left my plan much as Bill did. No mention had been made by the out-patient billing department when I called for pre-admission clearance (and confirmed my insurance information), by the radiology department (when I arrived and filled out more insurance forms), nor, needless to say, by my insurance company through a letter of notification. And when I had a Pap smear at my gynecologist’s office, and blood work drawn at another hospital just two years ago, I discovered again that I wasn’t covered. The analyses were performed by non-participating vendors even though I had made sure that the hospital phlebotomy lab and my doctor were in-network.

To admit that I was on the staff of both the hospitals just adds to my embarrassment, but it sure gave me pause. How many patients that I send for services could be caught in the same insurance booby trap, and what could I do to prevent it in the future?

Even if you ask the right question—do you participate in my plan?—of everyone you encounter, how do you check on behind the scenes personnel? And what if the practice or hospital cannot give you this information? My hospital Web site doesn’t list participating insurance companies and the radiology department receptionist still couldn’t provide me with the answer. And for my insurance company to check on any in-network status, I need the exact names of the various providers and labs.

This lack of transparency affects too many aspects of our health care and is confusing even when we have time to investigate benefits in advance. As a last recourse, you can always appeal the claim. But when we’re faced with a stressful illness or a medical emergency, we have little choice. The system can and often does take full advantage consumer's vulnerability the exact moment they need the services most. As Andrea discovered when she had to take her baby to the emergency room a second time, its physicians were not in her plan—none of the ER docs in the entire state of Texas were.

—Orly Avitzur, M.D., medical adviser, Consumers Union

For more information, read our reports on health insurance and health reform.

Comments

[shelliegh]

My son was injured right after birth by the hospital. They allowed him to bleed internally for hours until they called a life flight helicopter. They flew him to a hospital that was out of network. Emergency surgery, and a three week stay in NICU and we were being hounded before he even left the hospital. The second hospital that did surgery caused more damage with a scope before the surgery we had no proof or recourse against the first hospital that injured him. Our portion of the hospital bill was 60,000 the doctors portion was 2,000, and the list goes on and on. The medical flight crew was paid 9,000 by our insurance company and now we are being summoned in court to collect another $2,500. Many of the children in the NICU didnt have any insurance or were paid entirely by the state. Which leaves us to work to pay in more ways than one. Great job California and USA! The system takes better care of illegal aliens than it does a combat veteran and his family.

[cliff schuman]

i just had the same thing.. i went to emergency room in december 08 for a pain i wanted to have checked out. It was an emergency room hospital that was in network, co payment 75 dollars.. For months i got a bill for 303 dollars even though, it seemed all of procedures were covered minus the 75 co pay. After months of run around, i found out the$303 bill was from the doctor who was "out of network", in an "in-network hospital", and i was responsible for the bill. When I heard that i freaked out at the insurance provider. I had never heard of such craziness. "How was I to know.. should i ask the doctor in the emergency room,- are you in network, at a time of crisis, though this was an in network hospital".. what kind of system is this. How could you live with yourself working in an environment that is so duplciitous, that you cheat sick people at their time of need-- this is why we need universal health care, " i yelled to the insurance provider when she told me i was responsible. She then called the hospital, and then told me i will not be charged.
I spoke with someone who works in medical billing field later and she said this is one of tricks of the trade,, usually people just pay, unless you stand up for yourself.
Well thank god this was not a serious problem or who knows how much i would have to pay. Unless you stand up for yourself and start complaining or yelling it seems the insurance company/hospital will try to trick you as much as they can..
Who in their right mind can think its fair to go to an in network emergency room with out of network doctors. How is the sick, weakened patient supposed to know?
I just got insurance recently after years of not having any and i find it hard to see why i should even keep mine. It is Empire/Blue Cross Blue Shield. What kind of racket is this anyway.. I would have been able to work out something easier if i did not have health insurance.
It wasnt a huge bill,, but its the principle. How can a person afford to get sick in a country that makes it a premimum to make a profit out of sick people.. This is the sickest thing!!
i think people looking back on the US civilization at this time in history would view the coldness of a country that makes money, a profit out of people when they are sick.. And yet nothing is changed because of a the fear mongering of the "right" wing among us who try to scare us with the word, "socialism". Maybe we should scare them with the word, "compassion" and fight for a more just health care system.

[Barbara]

I was attacked in the face by a neighbor's cat. I am a careful consumer who knows the games insurance companies play so I called GHI to speak to the nurse and get a precertification/referral to an in-network ER. By the time I got to the ER, I was disoriented and in shock and bleeding profusely. The regular ER doctors cleaned the 3 wounds which were within 1mm of my right eye. They said that they were very deep and that they would not attempt to suture them and that they were calling the plastic surgeon on call.

A week after the surgery, I visited the doctor for post-op check up and removal of stitches. I was charged another $200 -when I gave them my insurance card I was informed that they were out of network and I paid out of pocket. The following week I was seen again by the doctor and charged another $200.

GHI reimbursed the doctor $3700. Two weeks later I received a bill from the doctor for another $3000. When I tried to negotiate with the insurance company -it went nowhere. When I complained to the hospital -they produced a record which made it seem as if I had asked for a plastic surgeon. My attempts to work something out with the doctor were answered by a summons to small claims court.

I was never asked if I wanted the plastic surgeon nor was I told she was out of network. If I had been, I might have said just clean it and butterfly it and I'll go to my in-network surgeon in the morning. It was already 3am. However, I was never given the opportunity to give consent or make a choice. Why should I be personally penalized?

There is no other business where a consumer can be charged for a product or service without their knowledge or consent. Why are hospitals, doctors and Insurance companies held to lower standards than used car dealers?

I am self employed so losing time for court is a financial hardship. On the other hand, perhaps in small claims court, the judge will be able to provide substantive justice on something that sure strikes the ordinary citizen as a scam.

Any suggestions of how to proceed? I have enormous legitimate medical bills from my husband's illness so I can't afford to hire an attorney.

[Annie Penrod]

Seen in an In network ER, admitted to same in-network hospital. Yes, the fun begins. I have only received one bill thus far- as they are just starting and I see one of the radiology groups was paid as in network (90% of allowed charges) by my insurance, even though they provider is out of network. This I thought was gracious as I was an in-patient, and they could have paid out of network, since provider doesn't participate with my insurance. However, the provider still wants to bill me for the difference.
I manage a medical practice, so I am fairly used to insurance tactics. However, the hospital staff is fully responsible for informing hospital providers of patient insurance. If they don't have inpt. staff in said network, then the hospital can pay the provider the difference, or tell them if they want in pt. work shared with them, they will have to take insurance allowable!

[Janet L]

On the consent to treatment/ promise to pay form I write in that the liability I am accepting is limited to reasonable and customary charges as determined by my insurance company. When they object, I state very loudly, in front of their other patients, that if they plan to do somthing unecessary or make unreasonable charges that I will plan to find another provider. They always give in quietly!

[B. Eastman]

I too am in Austin, TX. I called 911 and went to an in network hospital. After a month, the bills started coming. To begin with, there was the EMS ride. Why is the BASE FEE over $500.00, then they nickle and dime you and get the fee up to $600. When the insurance company got the bill (my insurance documents say that the EMS is covered at 100% after the $1000 deductible and by the time the bill was sent to the insurance company I had met my deductible. The insurance company tried to say it was an OUT OF NETWORK EMS. I asked them if I was supposed to call 911 and ask for an IN NETWORK EMS. I had the pdf file of the coverage documents opened and was telling them what pages to go to. They reprocessed it and paid the difference. Most of the doctors I saw were out of network. I called the hospital billing department and told them I had no control over all who treated me. Part of the problem is the doctors, radiologist, etc. are NOT employees of the hospital, but INDEPENDENT CONTRACTORS. I think the hospitals need to start HIRING all the staff (as EMPLOYEES) and then if the hospital is in network, everyone that sees you is in network too.

[Theresa Blackwell]

From what I understand, most hospital ER doctors in the Houston TX area are not tied to any insurance network of Doctors. It's by their design-they can charge as much as they want to without any strings attached. Why don't the in-network hospitals do something? My guess is they also get a piece of that pie.

[S. Chapman]

It's also worth noting that even if you have insurance that covers out-of-network care, it will probably only pay for so-called "reasonable and customary" charges. As we all know, that means you'll still be stuck paying 40-50%, or more, of any medical bill.

[Sharon C.]

Even though I have had numerous trips to emergency rooms and spent five months the hospital in the last three years, I never had to worry about a single bill or anyone out of the plan because I belong to Kaiser-Permanente, an HMO who knows how to provide good medical care and makes it easy for the consumer/patient.

[Terry]

In July of 2007 I went to the closest emergency room, an IN network facility, with a post-surgical infection. I had the experience described by many of the above posters. The doctors who treated me were OUT of network but I did not know that until I got the bills.
The biggest insult was this: the doctors decided I had to have an emergency cat scan and a nurse stuffed me into a wheelchair and raced me down the hall to a room that was WAY out of network. The cat scan took less than 15 minutes but months later I received a bill, just for the cat scan, for almost $10,000.
Like any self-respecting American, I threw away the bill. Over the next year I received numerous bills for the cat scan. The charge kept going down. I discovered that the cat scan provider had negotiated with my insurance company, probably more than once, and I finally paid a bill of about $1,000 that the provider turned over to a collection agency.
The medical insurance racket has to stop. America has to join the rest of the civilized world and have national health insurance.

[Otto Seeman]

if the bill is large, hire an attorney and file a complaint with the district attorney and the state attorney general. make a real pest of yourself. i've tried it and it works.

[Phil H]

Earlier this year my wife had knee surgery at an outpatient facility by a surgeon in-plan at an in-plan facility. Our provider Anthem Blue Cross of CT is the top rated plan in the state and I pay $1300 a month for my self-employed group plan.

Turns out the anesthieologist was not in plan and we got a $1400 bill! How were we supposed to know this ahead of time? Where was the disclosure? Did we have any choice? I think not!

Next week my son needs minor surgery and you can bet we checked, but the question is why should we need to? This is NUTS.

[Larry Goodman]

This doesn't have to end this way. My wife and I experienced a similar out-of-network bill and our insurance paid the bill though it took them a year of persistence on my part. If we have no control over the staff but the hospital is in-plan, the insurance must and will pay. As in most things, the squeaky wheel gets greased. Try it, you'll like it but it takes a lot of time.

[Frank Graham]

An insurance agent told me to write on the consent for treatment form they always have you sign: "If you are going to do anything to me that is not covered by medicare tell me first". Keep your copy.

[Kay]

This has happened to me more than once for hospital stays. I just flat out told the doctor in each case that he and his insurance staff were responsible for all the folks they employ during the care of me--these folks better all be Preferred Providers (in the parlance of my insurance company)or the doctor/hospital will be responsible for the difference. When doing the pre-check-in at the hospital, I tell them the same thing. We patients (especially when we're unconscious!) have no control nor knowledge about who all lays hands on us or any of our lab work, etc. So far, this has worked.

[Jim Moore]

My hospital bill was $2950. My deductible is $3000. My insurance company repriced the bill to $800 per their fee agreement with the hospital. The hospital still wants to charge me $2950 even though I will pay cash. There is a conspiracy between hospitals, doctors and insurance companies to rip off the self-insured. The whole system is corrupt and broken.

[Gina]

I have had gone through the same thing. We have a very reputable PPO Insurance Company and I was sent to ER with a Pulmonary Embolism...to a hospital in my network. It turns out their entire Emergency Department is staffed by Independent Contracter Physicians....out of network. Of course, we didn't find this out until we received our bill. I was dumbfounded and beside myself knowing there wasn't a thing I could have done differently, other than ask to go to another hospital, which in many "emergency" cases, isn't possible.

[Bill Danson]

I'm always amazed at the outragious system of American medical care.
In Canada we spend 10%of our GDP on medical care, one of the highest rates in the worl, except for the U.S. which costs 15% of GDP
All the advance nation nations in the world have government sponsored health insurance - except the U.S. where it seems to be a free for all with regard to Insurance companies and professional personal.
The great scare word in the U.S. is Socialism. Like socialized roads and socialized fire departments ect. Using this big scare word allows the Insurance companies to continue loot the system.
We have had Medicare in Canada now for nearly 40 years. In thjose 40 years I've never paid a doctor or a hospital for any service. Of course we do pay for Medicare through our taxes but everyone has equal access to the system
There are flaws in the system, mainly wait times, non theless, after forty years 80% of Canadian support the system ------- and it cost us 33% less then the American system

Bill Danson, Ottawa,Ontario

[Carl Lackey]

I would love to have more information on this. I recently when through a lot of claim experience at UNC with my wife and cancer. I got quite an insurance experience. Most of the events are much like this story covered... but it was more innocent on the part of the providers... to some extent.

I received a lot of non-payment charges from various physicians and related staff, medicines, and even the UNC Cancer Center chemo charges. All were the result of new procedure codes that had not yet been negotiated with EACH of the respective doctors, staff and/or facilities. Many drew escalation on my part, but I learned some of them were already escalated by the UNC insurance department. It simply was a part of their response to rejected claims. Some times it took two months to clear it by "negotiating", and by then I had already received a bill. Computers! Automation!

My doctor complained about the term "negotiation" because it's a joke. There is no negotiation. The insurance simply states what they will pay per procedure code.

[debchuck]

The physician/provider/hospital/billing/consulting medical practice group sure has it made. If one does not screw you, the other will!! It is almost like they do not talk to each other. And insurance companies are not in business to help people despite the premiums we pay. They are in business to immediately deny as much of a claim as possible and then wear the patient down until the remainder is paid just to get rid of the insurance racket.

I look forward to the day the practice of national health care is in place -- once and for all. The welfare recipients get better care than I do, and they do not have to consider networks, in-or-out-of-network pricing... they just go wherever they choose... often the most expensive emergency room service in any town.

I have no sympathy for doctors or hospitals or insurance companies. All are in cahoots and out to screw the consumer.

[Desiree]

This is absolutely outrageous. How could it possibly have gotten this bad????
Who is doing what to fix it????
What is one person to do?

[Randy]

Gosh a doctor getting screwed by the health care system, well maybe now we will get some powerful people with money to back politicians who by their very nature of the job are creeps but perhaps can put the brakes on a run-a-way healthcare system run by suits and greed mongers. To the insurance industry, how much money is enough?

[insurance billing]

Hey nice blog about the medical insurance boody traps. To ensure the quick and prompt payment of medical insurance claims to which you are entitled, you must make certain the staff you employ will be diligent in their efforts to assure a smooth transition from data entry to claim submission to the final payment of the medical insurance claim.

[bob]

I was involved in a motorcycle accident and was taken to a "in-network" hospital. I spent 5 days in the "ICU" with brain swelling. when i got the hospital bill weeks later, the TRAUMA TEAM that took care of me for the 5 days in the "ICU" was OUT OF NETWORK!!!!! this is totally absurd! if the hospital is in-network then the employed staff of doctors and nurses should be in-network also. I complained to my insurance co. but that was an even bigger joke! Insurance companies today are trying NOT to be in the RISK business! it's a bigger rip off than the price of gasoline.