Going to the hospital is traumatic at the best of times, when a person is alert and cognizant of all the obligations to complete paperwork and make sure that insurance companies have been duly notified and all procedures and treatments have been approved in advance and will be performed by in-network providers.
But when providers who are out-of-network muscle into the picture — a scenario that's all too common these days, as agreements with insurers terminate, providers move from one system to another, are acquired in a consolidation or simply do not participate in whatever plan the patient is covered by — that picture changes, usually drastically.
A Huffington Post article pointed out that, since this often happens during an emergency, the patient has very little control over whether he or she is being seen by a doctor — or has tests or lab work done — by an in-network provider. Instead, said patient is often seen or treated by a progression of people who aren't in-network and probably never have been, and that means that the patient is going to get billed for the difference between what the insurance company is willing to pay and what the provider intends to bill.
Recommended For You
According to the article, New York University researcher Dr. Kelly Kyanko found that 40 percent of people who use out-of-network care had no intention of doing so. Instead, they weren't told that a provider was out-of-network and so never really had a choice to decline the provider's services.
While some states do have some protections in place to keep patients from being buried under overwhelming bills arising out of out-of-network services, many do not — and even the protections that do exist aren't foolproof. While consumer advocates say that New York has the strongest provisions, even those might not have helped in one scenario described in the article: that of a woman in Santa Cruz, California.
A Consumers Union report said the woman had used an in-network hospital, gynecologist and neonatologist to have her baby, but when she ended up needing an epidural she not only was billed $3,000 for it by the out-of-network anesthesiologist, but later learned that the in-network hospital had no in-network anesthesiologists. None.
All that said, here are nine recommendations from the Center on Health Insurance Reforms at the Georgetown University Health Policy Institute and the Robert Wood Johnson Foundation on how patients can be protected from unexpected (that is, out-of-network) medical bills. Some of the actions would be necessary at the state level, while others are within patients' purview. Read and remember.
As reported in the Journal of the American Medical Association, a Harvard-led study of plan member choices showed that when employees spent more time reviewing plan options, they did not necessarily choose a cheaper plan. (Photo: iStock)
9. States can require increased transparency from health plans
Insurers can be required to tell participants whether the doctors they're about to see are in-network, and what will happen to their bills if they use out-of-network providers.
According to a Consumer Reports study, a third of Americans get "surprise" bills following a hospital visit. (Photo: iStock)
8. States can ban balance billing
Balance billing is what happens when the provider isn't in-network and bills the patient for the difference between what the insurer is willing to pay and what the provider is determined to be paid. If balance billing is banned, the provider can't charge the patient any more than the copay or deductible.
Two-thirds of Americans couldn't afford to pay a $1,000 bill if an emergency comes up. (Photo: iStock)
7. States can require insurers to protect patients from balance bills
That way patients wouldn't be left totally open to crippling bills that they never expected to receive — particularly if they followed all the rules to try to stay with in-network providers.
According to the AMA, 7 percent of bills paid by private health insurers have errors. (Photo: iStock)
6. States could set the amount that an insurer must pay a provider
Or that could create a dispute resolution process to arrive at a fair amount. That way patients would have some recourse and some protection from being expected to pay the full amount.
A bill was approved by the California legislature in September ensures that patients won't be charged out-of-network rates when receiving treatment at a facility within their network. (Photo: iStock)
5. Check on in-network status
Patients need to be sure that the physician they're seeing or the hospital they're going to is in-network.
While it has been known for network contracts to change, checking in advance cuts down on the possibility of being stuck with an out-of-network provider — and an out-of-network bill.
Despite having insurance, a Kaiser Family Foundation study says half of 2,500 respondents had trouble paying their medical bills. (Photo: iStock)
4. Will they take in-network rate?
If the physician or hospital isn't in-network, patients should ask whether they'll accept the insurer's payment as payment in full.
It can't hurt to ask, and could save a lot of money. If they say no, and it's possible to do so, look for another provider.
Basic medical coverage is a necessity to many workers, but it's important to find out what your plan pays for and what won't be covered. (Photo: iStock)
3. Know your coverage
Patients need to make sure they understand what's covered and what's not.
It's tough to negotiate for a lower bill if you don't really know what your plan will pay for, and how much it will pay.
A study published by the National Bureau of Economic Research says the financial toll of even a single hospitalization burdens the insured and uninsured alike. (Photo: iStock)
2. Negotiate any bill
Before paying an unexpected bill, patients should talk to their insurers and ask whether the plan will cover the full bill or the provider will accept a lesser amount.
The reality is that so many people end up in collections over high medical bills that a provider may be willing to accept a compromise amount that would be higher than what the provider would get from a collection agency.
Some projections say state marketplaces will see double-digit rate jumps, forcing higher premiums. (Photo: iStock)
1. Ask your insurer for help
Patients should contact their state insurance department to see if there are any laws that can help protect them.
A rise in the number of queries about legal protections from these unexpected medical bills could also help to spur such protections into being, as state insurance commissioners are made increasingly aware of the extent of the problems within their states.
© 2025 ALM Global, LLC, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.
