Although this video is corny, it is spot on and I couldn’t have done a better job writing a blog on a common problem. A provider saying they “take” or “accept” your insurance does not mean they are in-network. Rather it only means they welcome patients with insurance and generally will submit an insurance claim for their services to your health plan but it’s possible they are out-of-network (OON) and are able to balance bill you for the amount insurance doesn’t pay.

Balance billing is when an out-of-network provider attempts to collect the difference between the amount the provider charged for services and the amount the health plan (insurance carrier) was willing to pay.  Whereas when a provider is in-network, they must accept the “contracted rate” agreed upon with the insurance carrier and may not bill you for the difference.  Currently out-of- network providers are not under this same obligation.

The best way to guarantee the provider you are seeing is in-network is to call your health insurance carrier using the number on the back of your insurance card to confirm or most carriers have online tools for you to search for an in-network provider too.

However, in times of an emergency, it’s not realistic for you to previously have researched and figured out if a facility is in-network, nor may you even have the ability to select the emergency room, treating physicians, or ambulance providers.

Likewise, surprise bills can also arise when you receive planned care. For example, if you schedule a surgery at an in-network facility (e.g. a hospital) only to find out later (when the bill arrives) that the anesthesiologist did not not participate in your health plan’s network. (It’s very common for radiologists, anesthesiologists and pathologists to be OON.) In both situations, you were not in a position to choose the provider nor to determine that provider’s insurance network status.

Situations like these are reasons why there is currently a push in Congress to pass “balance billing” laws to alleviate Americans from receiving a surprise bill. Both parties in Congress agree, you should not be surprised by an out-of-network health care bill. There has not however been agreement on the the best approach to address them. It remains to be seen if a bill can still pass before the Senate’s recess in August.

Resources:

• Surprise Medical Bill Legislation Takes A Step Forward, But Will It Lead To A Step Back?
• Employee Benefits & Executive Compensation and Health Care Legislative & Public Policy Advisory: No Surprise, Congress Focuses on Surprise Billing
• An examination of surprise medical bills and proposals to protect consumers from them