Adding insult to injury, insurers are not required to count out-of-network charges toward Obamacare’s annual limit on out-of-pocket expenses.
Efforts by doctors, hospitals and other health providers to charge patients for bills not covered by their insurers are called “balance billing.” The problem pre-dates the Obamacare and has long been among the top complaints filed with state insurance regulators.
Because the issue is complex and pits powerful rivals against one another— among them, hospitals, doctors and insurers— relatively few states have addressed it. What laws do exist are generally limited to specific situations, such as emergency room care, or certain types of insurance plans, such as HMOs.
Obamacare largely sidesteps the issue as well. It says insurers must include coverage for emergency care and not charge policyholders higher copayments for ER services at non-network hospitals. While the insurer will pay a portion of the bill, in such cases, doctors or hospitals may still bill patients for the difference.
Related: You’ll pay a lot more to see the doctor with Obamacare
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2) Be aware you could be billed by an out-of-network doctor even at an in-network hospital. Some plans will cover those costs fully, especially for emergency care, but many do not. When possible, request a network doctor, anesthesiologist or specialist in advance of elective surgery. If you are billed by a non-network provider, call your plan to find out if it will cover the bill because you were at an in-network hospital.
3) If you get a balance bill, double-check to make sure the doctor or hospital is not part of your network. If they are not in your plan, check with your state insurance regulator to see if there are rules that might protect you, especially in an emergency situation. Ask the doctor or hospital to reconsider. If they won’t, complain to your health plan and whoever regulates it, as well as to your state’s consumer assistance program, if there is one.
4) Negotiate. If there are no plan policies or state rules to prevent the billing, negotiate with the providers to lower their charges to an amount close to what an insurer would pay. Your insurer’s website might have pricing information. Websites, such as Fair Health or Health Care Bluebook, can also help determine the prices of various procedures.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.
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