Balance Billing: What to Do When You Get Out-of-Network Bills From an In-Network Facility

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Healthcare is complex, and while some of our previous posts have kept things high level, today we are diving into a messy billing situation that many ER visitors encounter, including our friend Clark.

While cooking dinner, Clark accidentally burned his hand and went to the ER. He knew the ER was in-network and was shocked to get two expensive bills - one from the ER facility itself, and another out-of-network bill from the physician that treated him.

Clark called the Healthcare Hustlers to find out what was going on. We’ve outlined some lessons below:

  1. One visit to the Emergency Room can result in a patient receiving several bills. There is almost always one from the facility itself (the building where you were treated), another from the physician group that the treating doctor belongs to, and possibly a third from an anesthesia group that was involved.

  2. Because these bills are from separate business entities (a hospital, a physician group, and an anesthesia group), they may not all be in-network. You should check each explanation of benefits (EOB) to see how each service processed. Learn more about how to review medical bills here.

  3. If the Emergency Room was in-network and you were there for an emergency, you may have some options.

    1. Call your insurance company and ask them to reprocess as in-network, since you went to an in-network emergency room.

    2. Call the out-of-network physician group and ask them to write off the amount that is not covered by your insurance.

    3. Find out the legality of this practice in your state. The Commonwealth Fund has a useful chart (Exhibit 2)  that provides more in-depth, state-by-state legal guidelines based on various criteria. If you are in a state with legal protections, you could potentially pursue legal action.

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