HCA Midwest Health - September 06, 2017

I made the effort to go to an in-network facility, but was still charged out-of-network physician.

It’s never pleasant to get surprise bills—especially when you feel like you did all you could to avoid them. The fact is that most doctors who treat patients in hospitals don’t work for the hospital. And that means they contract separately with health insurers. It’s not as uncommon as we’d like it to be for hospitals to be in-network for your health plan while one or more doctors treating you are out-of-network.

At HCA Midwest Health, most of the time, if our hospitals are in your network, the doctors who may treat you there are, too. We also know that understanding coverage can be a challenge. That’s why we offer our HCA Patient Resource Center at 1-800-849-0829 to help navigate insurance-related questions.

You are taking the first step to avoiding out-of-network costs right now – by learning about the common ways people unintentionally go out-of-network.

How this happens

Doctors work IN the hospital, but most don’t work FOR the hospital. That means their practices need to have separate contracts with the health insurance companies. So even if all are in-network, you would probably still receive bills from doctors and the hospital. In addition, doctors and hospitals have contracts with many insurance providers and those contracts renew or change at different times throughout the year. That’s why patients are advised to check with both their doctors and their insurance companies to verify coverage in the days before a planned procedure.

Read more about why you receive multiple bills for the same hospital stay.

Preventing Out-of-Network Costs for a Planned Procedure

Most people think about finding a surgeon or specialist in their networks, but services like anesthesiology and radiology are often used – and those practices will have their own contracts with insurers, too.

The best thing you can do is to ask a lot of questions before your procedure. Make a list of all the different specialists or practices that might be involved in your care. It might look something like this:

  • Primary doctor or specialist
  • Surgeon
  • Radiologist
  • Pathologist
  • Hospital (and all hospital-employed staff and doctors)

Sometimes finding out the doctor’s name in advance is hard (anesthesiologists, for example) are often assigned to cases the same day as procedures. But, you can usually get the name of the anesthesiology group (or groups) that might be called in. And that’s all you need to know if any doctor in that group would be in- or out-of-network.

Once you have your list, talk to each group directly and with your insurance company to see if any would be out-of-network. If they are, you have a few options:

  • Try to find an alternative that is in network.
  • Negotiate in advance with the out-of-network practice either to pay a certain amount for services or to pay in installments.

Of course, choosing the right insurance company with a broad network of physicians in your area can help, as well as selecting a plan that offers some coverage of out-of-network doctors.

Handling out-of-network bills

Your insurance coverage may vary depending on whether your hospital visit was a true emergency. And those rules vary depending on the insurance company. As soon as you can after an unplanned event, talk to your insurance company. There may be steps you can take immediately to address any out-of-network concerns.

If you receive a bill that is unexpectedly out-of-network, talk to both the physician and your insurance company to understand your rights and options. Many providers will work with you, especially in cases where you had no control over who provided your services (such as an emergency surgery). But understand that neither the practice nor the insurance company is under any obligation to make adjustments.