Out-of-network charges have been in the news lately: stories about patients socked with outrageous bills from doctors who weren’t in their insurer’s network.
I’ll get to those charges in a minute, but first I want to say something about health care provider networks. Generally, the existence of networks benefits providers, consumers, and businesses that provide health coverage for their workers. It holds costs down, facilitates quality care, and reduces administrative burdens. If consumers choose an out-of-network doctor or hospital, it’s true that they have to pay a greater percentage of the bill (or even, depending on the plan, all of it). But a careful consumer can simply choose in-network care and not have to worry about all that. Right?
Most of the time. It’s pretty hard to be a savvy consumer in emergency situations or in hospitals, though, where whole teams of people can be involved in your care. In fact one hospital in New York actually put up a sign reminding patients to ask the doctor treating them if he or she accepts their insurance. You do have the right to ask for another doctor. Of course, you can only ask if you’re conscious. And even if you are, chances are good that your anesthesiologist or radiologist doesn’t belong to any network. What are you going to do? Politely decline to be put under for your operation?
Compounding this problem is the fact that some providers don’t clearly communicate their fees. Some bill the insurance company for the agreed-upon out-of-network rate, and then bill the patient even more if that rate doesn’t suffice. One large national insurance company has even filed lawsuits against certain doctors it feels are misleading patients and scheming to charge exorbitant amounts.
If you can’t always choose your provider, and you can’t tell what a provider is going to charge, you as a consumer are at risk of getting one of those crazy-high bills someday—even if you dutifully pay your health insurance premiums and carefully choose doctors in your insurer’s network.
So what’s the solution? I believe in appropriately-regulated markets and I don’t usually recommend legislative remedies for health care issues. But, in this case, the only solution I see is a ceiling on how much a provider can charge out-of-network patients—a ceiling that’s fair to both providers and patients, and one that gives everyone some peace of mind.
Health Care Perspectives 
Dave,
Very interesting subject! There should be remedies for those who are not in control of their own destinies! Maybe the Supreme Court will give us some direction this month on the Obama Care issue!
Thanks!
JAD
Transparency is needed. If patients knew up front what the cost for care would be they would have a better idea of their out of pocket exposure. Yes, the patient does not know what the “allowed amount” or UCR will be for the non-par provider, but at least it is a start. This works when you are voluntarily seeking services from a non-par provider and have time to do homework but not in an emergency situation.
I am so amazed at how simply and accurately Mr Oliker puts across the most pressing issues. Its in plain english and anybody even without health care knowledge can understand his blog. I am not a big blog person but I always make time to read his blogs cause its so interesting and striaght to the point. Waiting for next interesting analysis of industry critical issues..
Of course MVP could always publish their negotiated and contracted rates through the “find a doc” website, but knowing how long IT updates take (out of scope!), legislation will probably happen first. C’mon be a trend-setter and publish real information of cost and fees that will help your insured members to make real decisions.
Of late, I have had to explain to members why they are being balanced billed by out of network anesthesiologists, emergency room physicians, radiologists, and pathologists for services rendered to them at a participating facility when they had no clue these services would be provided by out of network providers. I feel like these providers are holding the members and insurance payors hostage as many of these providers refuse to even negoitate. They want what they billed, period. If they can’t make the insurance company pay they start billing the members and turn them over to collections for services rendered to them in an emergency situation or under circumstances where they have failed to dislose to the member their out of network status until after the fact.
Why do the facilities continue to utilize non-par providers? Why do we continue to contract with facilites that utilize non par providers? What pressure can be brought to bear by the insurers for the facilities to utilize par providers or at least willing to negoitate in these circumstances so that patients will not continue to be blind-sided and left feeling powerless?