Special Report: Why a Hospital Bill Costs What It Costs

Reader’s Digest investigates the shocking ways we overpay up to thousands of dollars on medical expenses, and how you can understand where your money is going.

By Kimberly Hiss from Reader's Digest Magazine | September 2012
Special Report: Why a Hospital Bill Costs What It Costs© Wavebreak Media/Thinkstock

4. Not every doctor is in your network.

Many doctors bill patients independently from the hospital they work in—and they’re not necessarily in your insurance network just because the facility is. Recently, a New York patient whose finger had been severed by a table saw went to an in-network emergency room but got stuck with an $83,000 bill from the out-of-network plastic surgeon who reattached the finger. Another New York patient scheduling heart surgery confirmed that both the hospital and the surgeon would be in-network, which should have left only a co-pay. But a nonparticipating surgeon assisted, resulting in a surprise $7,516 bill from just that physician.

Providers may not know (and are not required to inform patients beforehand) whether they are in-network. “We use the term RAPE,” says Cindy Holtzman of the Georgia-based Medical Refund Service. “It stands for Radiologist, Anesthesiologist, Pathologist, and ER doctor; that’s how we were taught in billing advocacy workshops to remember which specialties are most likely to be phantom billers that could be out-of-network.”

To save money: Ask who’s in. For a scheduled procedure, ask in advance whether any specialists you’ll need, such as the anesthesiologist, are in-network (and request only those who are). “You can’t always arrange it ahead of time, but if possible, do it,” says Metcalf. “It’s too late when you’re lying on the gurney.”

Add admission-form language. At the hospital, attach a statement to your admission paperwork that says you’ll pay for nonparticipating providers only if you’re notified in advance. Best-case scenario, your hospital will honor it outright. If not, you’ll be in a stronger position to dispute potential charges down the road.

Contest the charge. If you get an outrageous out-of-network bill, use out-of-network reimbursement data from sources like FAIR Health to negotiate with your insurance company for better coverage, says Jennifer Jaff, executive director of Advocacy for Patients with Chronic Illness (who herself saved $1,100 on a colonoscopy and endoscopy this way). You can also ask your insurance company to cover an out-of-network physician at your in-network rate, a strategy that Palmer has used successfully.

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