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What Is “Out of Network” and Why Is My Health Insurance Company Not Paying All of My Medical Bills?

David Humphreys Aug. 29, 2018

Help! What is “out of network” and why is my Health Insurance Company not paying all of my medical bills?

On an average day, a patient pays a visit to their doctor with standard cold and flu symptoms. The doctor orders a chest x-ray, calls a radiologist to take a look, and it turns out that everything's fine. Until…

Months later, the patient receives a bill. But now it's double, triple or even higher than expected — and budgeted for. As it turns out, the radiologist ordered by the hospital was out of the patient's network. That specialist group doesn't contract with any insurance network for a negotiated, lower rate (and instead charges four times the market price) and isn't covered by insurance. The patient doesn't know a thing until the bill shows up in the mail.

Physician groups, even those practices owned by your “in-network” hospital, have complete control over how much to charge. Hospitals decide which physician treats whom. And it's possible that they all make more money by assigning “out-of-network” physicians to vulnerable patients.

A patient could have gone out of their way to ensure that the surgeon for an upcoming procedure is in-network, and still be put under the care of an out-of-network anesthesiologist without being told — much less asked.

In an emergency situation, a patient should never have to worry about the insurance network of the person providing them care.

This practice of “balance billing” or “surprise billing” can affect uninsured and privately-insured patients alike, in all branches of medicine, from emergency care to general practitioners — though anesthesiologists, radiologists, and emergency room physicians have some of the highest rates of excess charges, according to studies.

Surprise medical billing can happen to anyone, and once the bill arrives it can be daunting to even consider fighting the charges.

If you're recently out of the hospital or currently fighting an illness, you may not be well enough to spend hours on the phone trying to contact your hospital, physician, and insurance provider. Even if you're a normal person with a busy life, you may not have those hours to spare — especially now that you have to try to pay this enormous and unexpected charge! It took a total of 9 phone calls and many hours for one doctor to get her insurance company and provider to agree to cover a surprise charge. The doctor, even with her extensive research and background in the field, claimed it took “an incredible amount of work.”

But you don't need infinite hours or a degree in medicine to fight back against out-of-network surprise billing. We encourage you to contact our law firm for a case evaluation.

You should also call your state representatives to fight for state protections against surprise emergency or out-of-network bills, against the interests of some powerful lobbying groups.

If you've already been surprised by out-of-network billing, you have options. No one should have to live with the stress of unreasonable medical bills, but many patients will need some help. Contact our law firm for a case evaluation.