What happened?
Mary was going in for bariatric surgery. She confirmed all details with her health insurance provider, including the authorization for services. On the day of surgery, Mary checked in at the in-network hospital. Approximately fifteen minutes before being taken to the Operating Room (OR), she met her anesthesiologist, who explained the process for anesthesia.
After surgery, Mary focused on her recovery and follow up visits. Three weeks later, she received an Explanation Of Benefits (EOB) for services covered, including the patient responsibility portion based on her plan. She was taken back that the anesthesiologist portion was not covered. The $3300.00 for the anesthesia portion was denied by her insurance provider, leaving that amount to patient responsibility. A week later, she received the bill for payment directly from the anesthesiologist.
Mary thought back and confirmed that she did get the authorizations for the surgery and thought this must be a mistake by her insurance provider. She called them, and they told her the EOB was correct. The anesthesiologist was out of network, and they are not obligated to pay out of network charges.
Mary was puzzled, it was an in-network hospital, why wouldn’t the providers caring for her be in-network?
Frustration and anger set in, how was this her fault? She had only seen the anesthesiologist fifteen minutes before surgery. Her focus was on her surgery, not inquiring if the anesthesiologist was in-network.
Why would Mary be responsible for the anesthesiologist bill?
Most insurance companies have contracts with large anesthesiology groups who serve in in-network hospitals. That said, some anesthesiologists may choose to work as an independent physician, and they need to get contracts with the insurance companies. If they don’t, or the insurance company refuses to contract, they are considered out of network.
The unfortunate part is anesthesiologists are on call making it hard for a patient to predict who they will get and if they are contracted with the patient’s insurance provider. In Mary’s case, her care was provided by an out of network anesthesiologist.
Should Mary pay the bill?
Mary should first call her insurance company and plead her case by asking for an appeal or reconsideration.
The denial/appeal may be upheld by the insurance provider as the insurer does not have to pay out of network costs. Also, because the bill is coming from a non-contracted group, they cannot protect Mary from being balance billed or sent to collections.
Mary can work with the billing company and plead her case and ask for a discounted rate and or payment plan. If Mary does not pay, this could impact her credit history.
Could Mary have done anything differently?
Anesthesiology is not the only specialty that may fall in this scenario. Radiology, Anesthesiology, and Pathology (RAP) can also be services you could receive a bill for if the provider is out of network.
- Mary could have discussed with her provider ahead of time that she only wanted in-network providers. This is a challenge even for her surgeon as h/she may not know the anesthesiology on-call schedule, but perhaps the surgeon can stress this to the hospital staff.
- As Mary completed the patient admissions paperwork, she could’ve requested for in-network providers only and in fact, put this in writing. The hospital staff will do their best, but there is no guarantee. Having it in writing may help in your appeal to an insurance company.
Bottom line – acknowledging that if you are going in for surgery, the last thing you want to do is think about negotiating a bill or confirming who is in-network or out of network. The unfortunate fact is if you don’t speak up, you could be stuck with paying the bill.
Final options:
Always consider your state regulations; for example, New York has a law that protects patients from balance billing. The Division of Insurance (DOI) is also a useful resource for education or filing a complaint.
Finally, if you have everything in writing and your insurer has denied the appeal, keep in mind the appeals typically go through the claims department. Another department to call is your member services number, usually on the back of your card. Let the representative know your concerns as they work on your behalf to keep you out of the middle, especially those beyond your control. They may consider providing a one-time service recovery that will help with payment of the anesthesiology bill.
An update, as we move into 2020. Many states are fighting the practice of surprise billing. Colorado passed House Bill 1174 to protect consumers from this act, effective 1/1/2020. It requires the insurance company, if performed in an in-network facility to pay the out-of-network provider.
A solution to surprise billing 9 news Colorado
This is a good reminder to always check with your local Division of Insurance (DOI) to be aware of the laws enacted that may protect you from these types of practices.