Out-Of-Network Health-Care Gotchas

Health care-you may think you're covered if you have health insurance. But Consumer Reports says think again. You can easily be socked with huge bills.

That's what happened to one woman after her son eneded up in the emergency room.

When Christine Knopps' son, Brendan, got a deep cut on his face, the ER doctor offered the option of a plastic surgeon for the stitches.

Knopp says, "He was bleeding from his head, so I wanted to do what was right by him."

The surgeon's bill was $2,900. Christine had assumed her insurance would cover the surgeon. Not so.

Knopp says, "We were pretty shocked. We had no idea that was going to become our responsibility."

The problem was that, while the hospital was in the family's insurance network, the plastic surgeon who stitched up Brendon was not.

Consumer Reports says one of the most common causes of medical sticker shock is going out-of-network.

Nancy Metcalf of Consumer Reports says, "A PPO plan might say that it will pay 60 to 80 percent of out-of-network care. That does not mean it will pay 60 to 80 percent of the actual bill, though. It means it will pay 60 to 80 percent of what the insurance company thinks the test or treatment ought to cost."

Consumer Reports found lots of examples of patients being hit with astronomical bills, including one woman who was charged $480,000 for back surgery.

Metcalf says, "Bottom line, stay in your network. If you must go out of network, research ahead of time what your insurance company will pay."

And also research waht the test of procedure should cost. Two services-Healthcarebluebook.com and Fairhealthconsumer.org-let you search the cost of medical services by ZIP code.

Sometimes you can use this information to negotiate with the non-network provider you want to use.

And if like Christine you get a big bill, don't just complain to the insurance company. Enlist your employer and your state insurance department to help resolve the matter.

Consumer Reports says you can end up paying more than necessary if you pay the first bill you get.

The charges may be the higher "list" prices.

Wait until you get your explanation of benefit or EOB to see what your really owe.


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