Say you survive a freak accident in a national park, or contract an infectious disease after an ill-advised dip.
Whatever the cause, pretty much everyone has to go to the hospital at some point, and in many cases, terms like "out-of-network" or "in-network" aren't what you want to think about when you have a broken bone that needs to be fixed, like, now.
That's when health care can get -- quickly, dramatically -- expensive.
Surprise medical billing for out-of-network care is actually a lot more common than health professionals and most policymakers previously acknowledged, at least according to a new study published yesterday in the New England Journal of Medicine. After digging through 2.2 million medical claims from emergency room visits over two years, researchers concluded 22% of emergency room patients were treated by out-of-network physicians. Those could be specialists like anesthesiologists or radiologists, despite 99% of the claims coming from hospitals that were in-network for patients.
Basically, even if you have the foresight to seek treatment at a hospital that accepts your insurance, the docs you see there may operate in their own networks, meaning you've just inadvertently received treatment from providers not covered by your plan. Weeks later, you're feeling great, when the other shoe drops in the form of a massive bill.
One-fifth of patients seems crazy high, but the problem is complicated
"No one knows this is happening this frequently," Zack Cooper, a health economist at Yale University who led the work, told The Washington Post. Per the research conduceted by him and co-auther Fiona Scott Morton, surprise bills could tally up to $623 per visit, on average, and potentially $19,000 for one patient they looked at. Talk about a huge bummer of a letter to open: "You owe $19,000!"
Rebecca Parker, president of the American College of Emergency Physicians, disagreed, calling the numbers "ludicrous" and the peer-reviewed study "totally out of the realm of what's true." Per the Post: "Parker said her organization has been examining the surprise billing issue for more than a year and often found that patients who receive surprise bills are dealing with the unwelcome discovery that their insurance plans simply cover very little."
The crummy part of it all is that this is simply the norm for how American health care works. Insurance providers make deals with hospitals and health care providers in-network, and to cover a portion of the cost.
"When a doctor is not part of a plan network -- even if they separately contract with a hospital to treat patients there -- they can charge much higher rates," Kristine Grow, a spokesperson for America's Health Insurance Plans, told NBC News. "That's when patients receive a surprise bill."
How you can avoid and deal with surprise medical bills
In an emergency scenario, there's not a ton to do, beyond trying to get to a hospital you know is in your network. For the record, if you have an emergency, no hospital can refuse treatment, per the Emergency Medical Treatment & Labor Act -- so get to the closest damn hospital you can find for the fastest care you need.
On the legal end, New York, California, and other states protect patients from some surprise nightmare scenarios like these, and some insurance providers will cover your bills after the fact, but ultimately the buck stops with you, the patient. To mitigate surprises, follow this quick checklist:
- Call ahead before a doctor's appointment to make sure you're in-network.
- Ask your primary care physician if any specialists or health care providers are in-network.
- Plan meticulously when it comes to major care or surgery, which could involve a number of specialists, anesthesia, physical therapy, and other factors.
- Get itemized bills, and be sure to check for any procedure or treatment you did not actually receive.
- Don't shy away from negotiation -- both before and after treatment.
"You, as the patient, have absolutely done the right thing," Cooper explained to NBC News. "You've gone to an in-network hospital, and a doctor who you didn't choose, who you couldn't avoid, ends up not being a member of your network and weeks later sends you a bill for tens of thousands of dollars that you're on the hook to pay."
This isn't a new issue. The Kaiser Family Foundation -- a nonprofit think tank focusing on health policy -- broke down federal and state responses to the problem of surprise medical bills earlier this year after doing its own research. It concluded numbly, "Data on the incidence and impact of this problem are limited. Federal authority to track the incidence and impact of surprise medical bills exists but has not yet been implemented."
The upshot is typically American. When it comes to figuring out your medical expenses, the responsibility rests with you, the patient, to navigate the frustratingly complex world of health insurance. And who knows what the future holds on that front?
H/T: The Washington Post, NBC News