Ouch! Have you ever received health care services from an out-of-network doctor? This means there isn’t a negotiated contract between that doctor and your insurance company. So you will most likely pay substantially more out-of-pocket expenses when using the out-of-network doctor.
There are a different ways in which you might incur out-of-network expenses. You might have a medical emergency that requires you or a family member receive care. You might be traveling and become sick while out of town. Or you may need to see a specialist that is not covered by your health insurance plan.
This situation has occurred twice for our family. First, my wife was in labor and had to have an emergency C-Section. The on-call anesthesiologist was out-of-network so we ended up paying a lot more for his services. In this case, I was grateful a doctor was available even though the final bill wasn’t too pleasant to look at.
Most recently, our son had to get ear tubes. I knew from prior experience to request in-network doctors up-front, but I forgot in this case (too busy I guess). So, at the surgery center I asked the question and unfortunately found out that our scheduled anesthesiologist was out-of-network. We could have rescheduled, but that would have probably required finding a new ENT (ear nose and throat doctor) since she partners with that particular anesthesiologist. Final charges yet to be received. 
While your insurance will most likely still pay out-of-network, it’s again far less because there isn’t a negotiated contract between the doctor and your insurance. With our insurance, the amounts billed above what are covered don’t count towards our deductible. If you’re in this situation, you may want to check your insurance plan, because you could also be required to meet a separate out-of-network deductible.
How can you avoid out-of-network charges?
1.) You need to make sure you know your insurance. Admittedly, this is not an area I’ve spent much time understanding, but it’s important and I have some work to do here. Its far better to know what your plan covers before visiting with your doctor’s financial counselor about an upcoming procedure or seeking health care.
2.) Proper health care is certainly a priority, but ask questions about the financial aspects. I’ve found doctors don’t typically like to get into the business discussions. That’s why most offices have a business manager or financial counselor. Set an appointment with this person and review coverage before moving forward with planned procedures. Stress you want to make sure providers are in-network. You can switch doctors before moving forward if needed.
3.) Don’t forget to negotiate a better deal. This is probably something I will do once we receive my final bill for my son’s ear tubes. I’ll contact the doctor’s office and talk to them about what my insurance will pay. I’ll then discuss them lowering the difference to something more affordable for us if it’s unreasonably high.
A New York Times article mentions you should tell the hospital and the doctor that since you weren’t made aware of out-of-network charges, the out-of-network provider should accept the fee your insurance is willing to cover. This is a great tip for such surprise charges as was in our cases.
4.) Stand strong! As we found out we were going to be charged for an out-of-network doctor, I told my wife that no one can manage these types of financial situations for us. In other words, no one was going to proactively tell us of the out-of-network charges. At the end of the day it’s our responsibility to be informed and ask the questions on the front-end.
Have you had experiences with out-of-network charges? If so, how did you handle them?
{ 4 comments… read them below or add one }
Always file an appeal with your insurance company and look to your insurance manual for language to quote or cite for your appeal. Often insurance companies will automatically deny an out-of-network claim when it should – or may – be covered under your policy.
Many policies will cover radiologists and anesthesiologist who are out-of-network at the in-network rate IF your actually doctor is in-network and the hospital is in-network. This is based on the fact that you can choose your doctor and hospital, but it’s out of your control who your doctor brings in to read your test results.
Finally, you can always petition to have an out-of-network doctor covered at in-network costs. This works well if the doctor is the only specialist in a certain distance from your home and the closest in-network doctor with the same specialty is 40 miles away. Just remember to petition your insurance company prior to treatment, if possible.
Option B – Move to Canada – where you don’t have to worry about that.
You go to the doctor, show them your health card. They fix you. You go home and not stress what it is going to cost you.
Some policies allow for out of network services for emergencies. And that’s reasonable. Calmly negotiating can go a long way. The “retail” price providers want to charge is always higher than what insurance plans cover, so there’s room to reduce the cost. Standing firm is exactly what you need to do.
i have never had any experience with this type of charges but after reading them through, i have seen that not knowing what to do when thry crop up can be a very costly mistake. Most of the people in my country do not havae health insurance so most of us don’t even know what these are and how to go about them.