by Lauren Agoratus
Most families are familiar with managed care and understand that they have better health care coverage if they stay within their plan’s network. However, even when families go to network hospitals, they are sometimes hit with surprise medical bills.
How Does This Happen?
Even if a hospital is in a family’s plan network, not all of the providers who provide services at the hospital may be in the network. It is important that parents know if individual doctors are also participating in the plan. This can be important to know for routine visits to a children’s hospital as well as for in-patient or emergency care.
Parents may have been diligent in finding both a hospital and also a provider who works there in their plan’s network. However, if their child needs surgery or other care, it is possible that the anesthesiologist, for example, may not be participating in their plan. Then the family receives an “out-of-network” bill.
The situation is even more difficult during an emergency. Families may have to go to the nearest hospital or perhaps get admitted or transferred to a hospital that may be out-of-network.
What Can Families Do?
- Use in-network hospitals.
- For medical appointments, check that the providers at the hospital are also in-network.
- If using Medicaid as secondary payor, get an out-of-state authorization. NOTE: Even non-participating providers can bill Medicaid out-of-network as secondary to private insurance.
- File a complaint, see https://consumersunion.org/insurance-complaint-tool/.
Families need to be vigilant about using in-network providers to ensure that their insurance will cover medical services. Plans should make information on network providers “transparent”, or disclose estimated costs out-of-network, so families don’t get unexpected medical bills. Some states have proposed protections, including for self-funded/self-insured plans. For more information on what families and advocates can do, see Resources below.
- Balance Billing: How Are States Protecting Consumers from Unexpected Charges?
- Resources from Consumers Union Health Care Value Hub:
- Webinar Recording from Consumers Union Health Care Value Hub: Addressing Surprise Medical Bills: New Research and State Approaches
- Surprise Medical Bills: Grid of State Legislative Solutions
- Insurance Complaint Tool
* NAIC Consumer Representatives Report, Ensuring Consumers’ Access to Care: Network Adequacy State Insurance Survey Findings & Recommendations for Regulatory Reforms in a Changing Insurance Market (November 2014).