How Do I Avoid an Unanticipated Out-Of-Network Bill?

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The best way to avoid unanticipated out-of-network bills is to plan ahead and utilize in-network providers as much as possible.  It is likely that you will pay more for your care if you utilize out-of-network providers.  Some plans (such as HMOs or EPOs) may not cover any portion of your out-of-network care.  OPIC has developed these tips to help you avoid receiving out-of-network bills.

 

First, before you receive any planned treatment, contact your insurer to make sure the doctors and hospitals you plan to use are in your network.  You will also want to confirm that you have any necessary pre-approvals in place.  Ask the hospital about the potential role of any out-of-network doctors in your treatment.  One frustrating type of unexpected medical bill happens when consumers receive care at an in-network facility from a doctor who doesn’t participate in the insurer’s network (for example, a radiologist, an anesthesiologist, or a pathologist).  You should speak with your insurer and the primary doctor responsible for any planned treatment to discuss the service provides typically involved in the treatment and investigate whether those service providers are in your network as well. 

 

Second, if you do plan to receive care from an out-of-network provider, contact the provider for the procedure price and then contact your plan to verify your financial responsibility.

 

Third, plan ahead for urgent care needs.  Locate the nearest in-network urgent care centers and emergency rooms.  Clarify your out-of-pocket costs for these care facilities with your insurer.  Since emergency room care can be significantly more expensive than care received at other types of facilities, plans often charge higher out-of-pocket costs if you use an emergency room rather than an urgent care center.  For example, you may pay a $500 copay for an emergency room, but a $100 copay for an urgent care clinic.  While you should use an emergency room to address an emergency, it may be much more cost effective to plan to use an urgent care clinic for your urgent care needs.

 

Finally, if you do receive a bill from an out-of-network hospital-based physician (such as a radiologist, an anesthesiologist, a pathologist, an emergency department physician, or a neonatologist) for more than $500 (after copayments, deductibles, coinsurance), you may have the right to mediation. 

 

Contact the Texas Department of Insurance at 1-800-252-3439 for a mediation request form or download the form at http://www.tdi.texas.gov/forms/consumer/mediationform.pdf.

 

 

 

I joined OPIC as a staff attorney in 2011.  I specialize in life, health, and disability insurance law.  I know that consumers can find themselves frustrated with these insurance issues at very difficult times in their lives—during sickness, after an injury, and after the loss of a loved one.  I am grateful that I can utilize my expertise to educate and empower insurance consumers as they navigate these challenges.