Wondering why you got an unexpected out-of-network medical bill?

Wondering why you got an unexpected out-of-network medical bill?

URBANA — You did your homework and chose an in-network doctor.

You went to an in-network hospital and an in-network clinic for your medical care.

So how did you end up with a surprise, out-of-network bill?

Concerns about surprise medical bills have picked up in recent years, and not only because health plan deductibles and other out-of-pocket costs for patients have continued to rise.

Sometimes, despite insured patients' best efforts to go to doctors and facilities within their health plan networks, certain parts of their care — for example, analysis of their labwork — may be done by providers on the outside.

Nationally, 57 percent of adults surveyed said they've been surprised by a medical bill they thought would be covered, according to a study released last August by the research organization NORC at the University of Chicago.

One in five of the surprise bills resulted from care provided by an out-of-network doctor, researchers found.

Out-of-network charges can be large because insurers negotiate rates with providers such as doctors, clinics and hospitals and offer their health plan members the best coverage for services in specified provider networks. And while some health plans, such as Preferred Provider Organization (PPO) plans, offer limited coverage for out-of-network services, patients in Health Maintenance Organization (HMO) plans don't have any out-of-network coverage at all.

Locally, Carle, Christie Clinic and OSF HealthCare said their care and service providers generally accept the same insurers accepted at their facilities. But there are exceptions.

Carle, for example, "in rare cases" works with labs that bill patients directly for certain kinds of testing, such as genetic testing, according to Carle spokeswoman Laura Mabry.

All employed doctors at Christie Clinic are in-network for the insurance plans the clinic accepts, according to Jaime Byers, the clinic's business services manager. Situations in which patients stand a higher chance of an out-of-network service are for "non-routine things," she said.

Some potential out-of-network situations to be aware of are cases in which biopsies are sent out of the clinic for a second opinion, drug testing (processed off-site) and procedures that involve the use of a mobile anesthesia provider or a contract assistant surgeon, Byers said.

Christie Clinic also uses an outside company to supply Holter monitors, which record patients' heart activity over an extended period while they're outside the clinic, she said.

Byers said patients are informed ahead of time when a mobile anesthesia provider will be involved, and the clinic's contracts with assistant surgeon providers require that patients can't be balance-billed for what their insurers won't cover.

There are also warnings in consent paperwork patients sign about the possibility of out-of-network charges, so it's important for everyone to read and understand what they're signing, Byers said.

"We do our best to inform the patient to say, hey, there may be another bill," she said.

Know your network

Health plans in Illinois are required to keep their provider network information posted and up to date, and failure to pay attention to what's in — and out — of network can also result in unpleasant billing surprises.

Four years after CampusTown Urgent Care in Champaign opened, for example, it hasn't been able to line up a contract with Health Alliance Medical Plans that would make it in-network for Health Alliance members, said Dr. Tom Pliura, a physician and attorney who owns the center. Students using that center are warned about that, he said, and some go ahead with the urgent care visit anyway.

Sarah Bush Lincoln Health Center, Mattoon, exited the Health Alliance network last year over a business dispute with the insurer, though the system provided extensive notice in its service area about that, according to Sarah Bush Lincoln spokeswoman Patty Peterson.

The state's Network Adequacy and Transparency Act offers some protection from out-of-network charges for people who make their best effort to get their health care within their specified networks "as evidenced by accessing the provider directory, calling the network plan and calling the provider," when it's determined the insurer doesn't have enough providers or those in the network require the patient to travel an unreasonable distance.

This protection comes with some caveats, however. It doesn't apply when patients willfully seek their care out of network or to HMO health plans.

OSF HealthCare posts all the insurers accepted at each of its facilities, "but it is always best to check directly with your insurer," said Laurie Hurwitz, an OSF senior vice president. Patients who are in-network for OSF Heart of Mary Medical Center in Urbana and OSF Sacred Heart Medical Center in Danville are also typically in-network for any of the professional services they receive at those hospitals, including pathologists and radiologists, she said.

Doctors providing care at Sarah Bush Lincoln also participate in the same health plans as the hospital, according to the system's vice president of finance, Dennis Pluard.

"There's very little that we send out," he said.

Ask questions

To avoid surprise medical bills, patients are also advised to ask thorough questions in advance of their medical care about every step that will be involved and every medical provider and facility that will be involved with each service.

Ask the provider for the billing codes for each service, then run them by your insurer.

"Any time you go for a lab, you should ask: Will any of the labs be sent to an outside lab?" Byers advised.

Health care tends to happen quickly, she said, "like they say the mole looks suspicious, we need to remove it, and you go into panic mode."

Patients don't ask their doctors enough questions ahead of time, she contended.

Such as, Byers said, "'I'm having my gall bladder removed. What are you going to do with it?'"

Byers said many patients also don't understand their deductibles, where to go for care within their networks and how their insurance works.

"It's really important to be educated as a patient," she said.

Pliura said health care is unique in its billing because the prices of medical care aren't posted the way they are with, for example, a gallon of milk. You don't buy milk you thought was a dollar, he said, "and the grocery store sends you a $10 bill for the milk."

"My advice is patients should not hesitate to ask ahead of time: Am I covered, do I have insurance coverage, what is my responsibility going to be?" he said.

Know your rights

Here are protections under three Illinois laws applying to surprise medical bills:

Since 2017

➜ Health plan members who make a "good faith effort" to use preferred providers for covered services can't be billed for out-of-network charges if it's determined the insurer doesn't have a sufficient network. This doesn't apply to Health Maintenance Organization (HMO) plans or if someone willfully chooses a non-preferred provider.

➜ Patients' share of the bill for emergency care isn't dependent on whether it's done by a preferred or non-preferred provider.

➜ Health plan members must be given 60 days notice if their health provider leaves the network.

Since 2011

➜ Patients can't be balance-billed for the amounts their insurers don't cover when they receive care from out-of-network radiology, emergency room, anesthesiology, pathology and neonatology providers at in-network hospitals or ambulatory surgery centers.

Since 2007

➜ During admission or as soon as possible in the care process, hospitals must give patients notice that they may receive separate bills from affiliated health care professionals, and, if applicable, that some hospital care providers may not be the same insurance plans and networks as the hospital.

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