A Costly Out-of-Network Surprise | WSJ | 6.24.05
What Happens When Your Hospital Is In-Network, But the Anesthesiologist Isn’t?
When Tom DiBari and his wife took their infant son, Jackson, for heart surgery in January, they had checked that both the hospital and the surgeon were in their insurance company’s network. So how did they end up getting billed for nearly $15,000 in charges for out-of-network care?
It turns out that during Jackson’s eight-hour surgery at Morgan Stanley Children’s Hospital of NewYork-Presbyterian, a second surgeon was brought in who wasn’t part of the network that’s maintained by the family’s insurance company, Aetna Inc. The family was charged for almost all of that second surgeon’s $15,000 bill, Mr. DiBari says. Aetna has agreed to pay 10%, says Mr. DiBari, who says he plans to appeal the insurer’s decision. (Citing patient-privacy regulations, Aetna declined to comment on the specifics of the situation.)
For people with health insurance who expect that their major health costs will be covered, out-of-network doctor bills from hospital visits can prove a costly surprise.
This issue occurs at many hospitals, and with many insurers. Often, the out-of-network physician is somebody such as an anesthesiologist or radiologist, who helps with a patient’s care but isn’t the main doctor in charge, say insurers and hospitals.…
OOPS = out-of-pocket services = out-of-plan-services
A good article about a very common problem. In an emergency setting the OOPS provider will usually be covered, and if not an emergency setting dealing with the OOPS provider prospectively with the payer may alleviate or lessen any problems. There are many situations where the service is unique or the number of in-plan providers is very small or singular at a particular hospital—the payers should take that into account on appeal.
4 Comments
And I thought this sort of thing only happened to me!
And I thought this sort of thing only happened to me!
This is a significant issue for physicians. Insurance company “A” signs a contract with Hospital “X” as the network provider, at a reasonable rate…..then offers the physicians there an unacceptable contract. So, the physicians don’t sign, and when patients show up with emergencies, they are understandably frustrated. The physician then spends 6-12 months trying to get paid, and the patient ends up often in collections. Insurance companies need to make it clear that not all physicians at a “network” facility may be network providers.
This is a significant issue for physicians. Insurance company “A” signs a contract with Hospital “X” as the network provider, at a reasonable rate…..then offers the physicians there an unacceptable contract. So, the physicians don't sign, and when patients show up with emergencies, they are understandably frustrated. The physician then spends 6-12 months trying to get paid, and the patient ends up often in collections. Insurance companies need to make it clear that not all physicians at a “network” facility may be network providers.