How to Deal With Out-Of-Network Medical Costs

Have you ever received medical care from a doctor or hospital that’s outside of your insurance plan's network? Were you surprised when you received the medical bill?

There are many reasons why someone might choose to receive care that’s out of network. Perhaps the best doctor specializing in the type of treatment you need isn’t covered by your insurance plan. Maybe your insurer no longer covers your long-time pediatrician. Sometimes you don’t even have a choice about where to go; you might need emergency care right away and rush to the nearest healthcare provider. Whatever reason you might have for receiving out-of-network care, don’t be surprised when an expensive medical bill that comes your way.
Related: How to Save Money by Negotiate Costly Medical Bills
A report by America’s Health Insurance Plans, an insurer trade group, found that some out-of-network providers charge exorbitant prices for their services. In some instances, the report found that out-of-network providers charge nearly 100 times more than what Medicare would provide for the same service in the same area. In New York, for instance, one doctor charged a patient $115,625 for a lumbar spinal fusion -- 62 times the Medicare fee of $1,867. 

“As we shine a spotlight on the affordability issue, we encourage policymakers to look at how much is being charged for services, particularly since there is often no relationship between higher charges and higher quality of care,” said AHIP President and CEO, Karen Ignagni, in a press release. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”

To protect yourself from having to pay startling fees for using out-of-network care, we’ve come up with a list of things to do -- before and after treatment:

Before Treatment

1. Don’t go out of network

Of course, the easiest way to avoid a painful medical bill is to simply avoid using out-of-network providers. Unfortunately, it’s not always possible.

2. Don’t assume

Your doctor is covered by your insurance, but don’t assume that anything he or she orders for you is also covered. For instance, he or she might want you to see a radiologist, but the one you’re recommended or sent to may not be covered by the insurance network. Double check to see that every procedure or test is covered by your plan.

3. Get familiar with your plan

Before you receive any treatment, you should know what your insurance plan covers. Your insurer should have a document called 'Summary of Benefits and Coverage' that outlines your plan’s features. You should also call your insurer and check to see what they will cover. In addition, ask your insurer about how it decides what it will pay for out-of-network care -- and make sure that you have a current list of providers that are in the network.

4. Research

If you must go out of network, then, before your medical visit, ask the provider how much you will be charged. You can try to negotiate prices ahead of time. Look to see what other providers in the area charge for the procedure or test you need and use that information when negotiating. You can also get an idea about prices in the Fair Health, Healthcare Blue Book. If the provider does agree to lower the price, get it in writing if possible.

After treatment

1. Negotiate

Call the provider and tell them that the bill is unaffordable. Ask them if they can lower the bill to a more affordable amount or put you on a payment plan. Use the research you conducted about typical prices in the area to get a lower price or discount. If that fails, complain to your insurance company, the provider, or your state insurance department.

2. Dispute false charges

If you find errors on your bill, notify your insurance company. Your bill should include a procedure to file an appeal if you find something is in dispute.

3. Look for an advocate

A state health insurance consumer advocate or a medical billing advocate might be able to help you negotiate lowering your bill. You might have to pay for the services of an advocate, so be careful that it’s worth the cost. If you will save far more on your bill due to the advocate’s knowledge, then it might be worth it.