Gaps in the Network

Think your hospital stay is covered? You may be in for a surprise.

By Amy Esbenshade Hebert, Reporter

From Kiplinger's Personal Finance magazine, November 2005

When Jen and Scott Sergio learned they were going to become parents for the first time, they tried to cover all the bases. The Falls Church, Va., couple contacted their insurer, Excellus BlueCross BlueShield, to make certain it would pay for both the hospital and Jen's doctors. Reassured that they were covered, the Sergios settled back to await what they hoped would be a complication-free delivery.

But it didn't work out that way. The baby's heart rate plummeted during labor and Jen needed an emergency cesarean, after which her newborn daughter, Morgan, spent eight days in the neonatal intensive care unit at Inova Fairfax Hospital. Morgan made a quick recovery -- but the complications were not over. The neonatologists weren't in the BlueCross network, so the Sergios were billed $6,000 for Morgan's care. Says Jen: "I had no idea that was even possible at an in-network hospital."

The Sergios' experience isn't uncommon. If your hospital care goes beyond your primary physician or surgeon to include anesthesiologists, pathologists, radiologists or even an additional surgeon or doctors in the emergency room, your insurance might not cover the cost. The out-of-network charge for a pathologist who analyzes your lab work may be only a couple of hundred dollars. But if your baby ends up staying in neonatal intensive care for a few weeks, the tab could be closer to $20,000 more.

Dr. Who? When your hospital stay isn't an emergency, you have time to plan. For example, if you're having surgery, it isn't enough to know that your surgeon is a member of the network. Ask the surgeon who will provide your anesthesia, and make sure that the doctor or nurse-anesthetist also participates. "Patients routinely tell us that they don't even know who the doctor listed on their bill is," says Nora Johnson, of Medical Billing Advocates of America, which specializes in resolving billing issues.

Check to see if the pathologist is covered, too. If you have a choice, tell your primary doctor you'd prefer a physician in your network.

You won't necessarily get your wish. If the neonatologists on a hospital's staff are members of the same practice, it's likely that all or none of them will accept your insurance. Or, an in-network specialist may not be available. In that case, ask if the scheduled doctor will accept lower, out-of-network coverage, advises Tom Bridenstine, managed-care ombudsman for the Virginia insurance bureau. The doctor may be willing. "The problem occurs when a doctor who provides services expects to be paid at a certain level and then isn't," says Bridenstine.

If you can't work out an arrangement with the doctor, talk to your insurer. Aetna, for instance, occasionally gives advance approval to cover a nonparticipating doctor, says spokeswoman Karin Rush-Monroe.

In an emergency, you don't have the luxury of planning. But you can be prepared, and maybe avoid unpleasant surprises, by reading your plan's provisions to see what coverage to expect.

Resolved. If you end up with out-of-network charges that a phone call can't resolve, file an appeal. That's what the Sergios did, with the help of the Fairfax Neonatal Associates' billing department, which wrote letters to the insurer on their behalf. After two appeals, the bill was covered, minus $500 for an out-of-network deductible.

Let the hospital and doctors know that you are appealing so they don't send the bill to a collection agency. If your hospital has patient advocates, use them, and ask the provider's billing department to help. For additional assistance, contact your state's insurance department.

As the Sergios discovered, even if you're successful, it's unlikely that the entire bill will disappear. If you can, stash some extra cash in your flexible spending account at work to cover out-of-pocket expenses.

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