Beware of Out-of-Network PPO Providers

Insurers continue to look for ways to control costs. While using the term “consumer-driven,” many of the changes are not in the best interests of consumers. One technique that continues to grow is the creation of smaller networks of doctors and hospitals. Employers enjoy lower premiums from insurers, but workers are challenged with reduced access to providers.

To make matters worse, many in-network facilities contract with out-of-network staff, including anesthesiologists, emergency room doctors, surgical assistants and lab technicians. Consumers access what they think is covered care, only to receive unexpected bills. An estimated one-third of American adults with private insurance are victim to such surprise medical bills every 2 years, according to a 2015 survey by Consumer Reports. Of those who have attempted to resolve such bills, only 28% were satisfied, according to the same survey.

Hospitals in most states are not legally required to inform patients as to which staff are contracted and therefore non-network. In-network doctors typically aren’t aware of which staff, services, devices and drugs are not covered. So even the savviest consumers are likely to receive unexpected bills.

National legislation to fix the problem, like most other legislation in our divided Congress, has not moved forward. Some states have focused on the problem, but none to date have outright prohibited the practice. For example, for emergency care in Florida and California, providers are no longer allowed to surprise-bill. Currently, New York has the most comprehensive legislation. Insurers and providers are now required to engage in arbitration to decide payment responsibility.