Q & A: June 2019

Q & A: June 2019

How Can My Grandmother Know When She’s Getting Treated By Non-Network Doctors?

Q:  My grandmother received a ridiculously high and unexpected medical bill (more than $13,000) after an emergency room visit, even though the emergency room was part of an in-network hospital.  What can we do to contest this bill and protect her from bills like this in the future?

A:  Your grandmother is not alone.  Recently Kaiser Health News reported on a woman who suffered a massive heart attack, and then developed an infection that kept her in the hospital for a month, some of it in intensive care.  Her bills totaled more than $454,000 of which she was told she owed $227,000 after her health insurance paid.  Her surprise bill is a problem that has been described as a new “national epidemic.”

In fact, a recent poll by the nonpartisan health policy group, Kaiser Family Foundation, indicates that in the past year, 4 out of 10 respondents said they had an unexpected bill — one that was not covered by insurance — from a hospital, doctor, or lab.  The problem is so widespread, and has become so egregious, that general outrage over the issue has turned ending surprise medical bills into a rare bipartisan opportunity for Congress to take action.

Surprise bills most frequently occur when patients are treated in hospitals and emergency rooms by doctors and medical professionals who aren’t part of their health insurance network.  For people age 65 and older, the problem would tend to affect Medicare patients who are enrolled in a Medicare Advantage plan which has networks of doctors, hospitals, and labs, and pharmacies under contract to provide services to plan enrollees.  When emergencies occur, patients are generally taken to the closest emergency room and treated there no matter whether the doctors are participating providers or not.  Consequently, emergency rooms are a leading cause of surprise bills because doctors may not be part of your health plan network.

That said, if you know ahead of time that your grandmother is going back to the hospital for any type of procedure or treatment, check with the admissions or billing department and ask whether the services that your grandmother will receive will come from in-network providers.  In particular, ask about anesthesiologists, radiologists and pathologists, people we frequently never see.  The same is true for labs and imaging.

You can help your grandmother by filing a formal appeal with her insurance company to get coverage for the bill (or bills) in question.  Insurers may help with the process and negotiate the charge.  You should also check with your State Insurance Commissioner or regulator.  Some 21 states have laws protecting consumers from surprise medical bills, if they’re covered under a state-regulated insurance policy.  In some case, the amount you pay out of pocket is regulated.  TSCL also strongly recommends that you locate your area Agency on Aging, senior center, or Social Services department and ask if there are any patient advocacy groups in your area that help with medical assistance.

TSCL supports legislation that would address surprise medical bills and strengthen patient protections.  Says Shannon Benton, Executive Director of TSCL,  “Patients should not be caught in the middle, or left standing holding the bag full of bills when providers can’t settle the bills in a fair way with insurers.”


Sources:  “State Laws Ban Surprise Medical Bills.  She Got One for $227K and Fought Back,” JoNel Aleccia, Kaiser Health News, March 22, 2019.  “Surprise Medical Bills Sending Consumers Into Shock — Here’s How To Avoid Getting Hit,” Walecia Konrad, CBSNews.com, March 15, 2019.