Sep 07, 2018
In more than 15% of inpatient admissions, a patient gets a bill from an out-of-network provider even though they used an in-network facility, according to a national study of large employer plans by the Henry J. Kaiser Family Foundation. Researchers who studied large employer health plans found that it happens most often with emergency care and for services for psychological or substance abuse. Thanks to a California law that went into effect last year, patients have some important protections.
Those who visit an in-network facility, such as a hospital, lab, or imaging center, are only responsible for their in-network share of the cost, even if they are seen by an out-of-network provider. The law applies to non-emergency services. The law does not cover self-insured plans regulated by the Dept. of Labor. All out-of-network providers who deliver services at an in-network facility have to accept what the insurer normally pays a doctor on contract for the services or 125 percent of the Medicare rate, whichever is greater.
If you’re willing to pay more for an out-of-network provider, they can bill you at out-of-network rates if you sign a form at least 24 hours before you receive care. The form must include an estimate of your cost and inform you that you can receive care from an in-network provider instead. That exception is a good reason to start reading medical forms before signing them! While policymakers have focused mainly on surprise billing, the study authors say that other policy interventions may need to be considered. Even though state and federal laws require adequate provider networks, there doesn’t seem to be an increase in access to in-network care for mental health or substance abuse services.
There may be a shortage of high quality providers in the networks. Plans may not be providing a big enough reimbursement to attract them. Also, more information about care patterns and plan networks is needed to determine why out-of-network bills are so common for these services.
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