When "In-Network" Really Isn't An Option
A dog bite. A broken arm. A person with Type 1 diabetes with a severe stomach bug and high ketones on vacation. Anaphylaxis from an accidental allergen exposure. While these aren't all necessarily equal in severity, they all could warrant immediate medical attention. Most insurance plans have a clause that says in a true medical emergency you can go to the nearest emergency room (ER), even if it is out-of-network. And that is great for addressing immediate needs. But what do you need to know to ensure you pay the correct bill?
Many years ago, I was bit by a client's dog while on a business trip. We wound up in the local ER, where I got stitches and a tetanus shot. When the bill came, I paid my "portion." It wasn't until months later that it dawned on me that I had paid an "out of network" copay for the visit. I called my insurance and told them it had been a medical emergency and that I went to the nearest ER. They reprocessed my claim as "in-network" and I received a refund of the difference.
This doesn't just happen with emergencies though. Last year I had scheduled preventive MRI at an "in-network" facility. The radiologist who read it and wrote the report isn't contracted with my insurance. Did I have a choice about the radiologist at the hospital? No. Were there any "in-network" radiologists at the hospital? No. So I couldn't have used an in-network provider. I got a phone call from the radiologist's billing service telling me my claim had been processed by my insurance and that I needed to pay my bill. I asked what the total charges had been and what I owed...did some quick math and realized I was being charged about 30%, which was my out-of-network" coinsurance. This time it took multiple phone calls over several months to get my insurer to process it correctly at the "in network" rate...which saved me about $90!
It's important to understand the basics of your health insurance plan: whether or not you can go to any hospital in an emergency, how they handle non-contracted (out-of-network) providers who may provide care while you are at an in-network facility, and the differences in cost between those options so you ensure you are paying the correct amount for care.
It would be easy to pay all of my medical bills without analyzing them. Instead, I take the time to ensure not only that my insurance has paid their portion, but that they have paid the correct amount based on MY benefits. And I always ask the provider if they offer a discount for payment in full. I'm sometimes pleasantly surprised when I get a 5-15% discount on what I owe!