Out-of-Network Follies with Health Insurance

by CoVaBizMag

“We just got another $2800 bill from Johnny’s surgery. From the anesthesiologist. I don't understand how if we hit our deductible. They say he's ‘out of network’ so insurance is not paying, and they are billing us.”

Beside a necessary changing-of-name, the above quote is an exact text from my sister, received on March 27, 2018. Sadly, this wasn’t the first time we’d discussed the issue.

“Wasn’t the other bill from the anesthesiologist also?” I replied, referencing her son’s first surgery from a little while back.


And then: “I'm on the phone. She is saying we are going to have to appeal to the insurance company.”

“Did you look over whatever you signed going into the hospital?” I asked. “And, what did they say about ‘sneaking in’ their out-of-network docs?”


Followed shortly thereafter by:

“I'm gonna cry.”

Have you heard this one before, yet? Seen the stories in the New York Times?

The language of ‘health insurance’ is complicated and difficult to master. We know this. There are copays and co-insurance, there are HMOs and PPOs and POSs. There are deductibles, and HSAs, and FSAs, oh my!

And, there are the ‘networks’ which, in the simplest form, are agreements between doctors and insurance companies on payment terms. If a doctor treats you who does not have a contract with your insurance company, (s)he can charge you anything (s)he wants. “Out-of-network,” it’s called.

“This doesn't make any sense. They've submitted like ten different bills. The EOBs and bills don't even make sense.”

My sister’s no dummy. In fact, as a veterinarian, she does understand a good bit the difficulties that arise when dealing with money issues under trying circumstance. She also happens to have a brother who is a physician and who, I can safely say, understands a decent amount about health insurance.

“You want an itemized bill of all charges,” I texted her while she was on the phone with the hospital. “You also want to see any and all paperwork you signed that they claim allows them to come in as out-of-network, even though you told [the] hospital beforehand your insurance and your network.”

Many hours and back-and-forth texts later:

Just spent close to 2 hours on phone calls to find out that I have to snail mail an appeal to the insurance company.”

Followed immediately by: “So frustrating.”

“Do some social media posting. With names,” I told her.

Self-advocate folks. Use your tools. And, continue to be smart.

About the Expert

Pediatrician Dr. Bryan Fine has been a physician for more than 15 years, and is the founder of Percentric, an innovative, physician-led health benefits optimizer. Visit Percentric.com to learn more.

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