The other day, I was in the car when I heard a commercial for a bariatric clinic offering lap-band surgery. The commercial ended with these words: “…your PPO insurance should pay.” This might lead someone to believe that their insurance would cover the entire procedure. It. Does. Not.
This is by no means the only statement that may, purposely or not, mislead a consumer. The financial consequences of seeing an out-of-network provider are profound. Absent some kind of negotiation, you’ll be responsible for the “list price” of any medical care you receive. If your insurance plan is a PPO or a POS (a plan with out-of-network benefits), you’ll be billed for the difference between a procedure’s list price, and the amount allowed under your health plan. That allowed amount may be a fraction of the list price, and you’re on the hook for the remainder. This is called balance billing. And if you have an EPO or HMO that limits you to in-network providers, you’ll be responsible for the full list price of any service rendered by an out-of-network provider.
The problem’s made worse because some healthcare providers play a little fast and loose with the terms. A doctor who says they “accept” or “take” a plan, may simply be saying that they will bill the plan. You’ll be responsible for any balance due.
So what do you do? First, make sure your provider is in-network. You can check with your insurance carrier or on your plan’s doctor search site. But be careful. Your insurance carrier may offer many plans and many networks. Make sure your provider participates in your particular plan.
And when speaking with a provider, you have to be very specific about asking “are you an in-network provider in my health plan.” This leaves little room for ambiguity. It’s also recommended that you make sure that any ancillary services are performed by in-network providers. Your annual physical, for example, may include a blood draw, EKG and lab work – all done by different providers even though everything was taken care of in the same physical office. So make sure those providers are also in-network.
It’s the only way to avoid having a costly out-of-network experience.