Current Weather
The Spy FM

When Out-Of-Network Charges Pop Up, Try An Appeal

Filed by KOSU News in Health.
June 21, 2011

When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma.

Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.

When the Wolfes appealed the decision to their health plan, the insurer relented and charged them the lower, in-network rates instead. Their story illustrates two important realities about health care: Out-of-network charges are a routine problem for many people, even when the hospital itself is in network, and appealing a health insurer’s decision is often successful.

A recent study by the General Accountability Office found that insurers denied claims more frequently for billing errors than because the claim was considered medically inappropriate. Patients who appealed the decision to their health plan won between 39 and 59 percent of the time. If they lost at that level, they won about 40 percent of the time if they appealed the decision to an independent review organization.

The health care overhaul gives patients the right to appeal health plan decisions to both their health plan and, if necessary, an independent external review panel.

“We see this a lot,” says Candice Butcher, CEO of Medical Billing Advocates of America, referring to out-of-network coverage disputes. There are generally two ways to handle it, she says, both of them often effective.

First, try calling the insurer and explaining that you used an in-network hospital and were unaware that the doctors who attended you were out-of-network. That often does the trick, Butcher says.

If it doesn’t, try contacting the out-of-network physician directly and explaining that you weren’t aware that he was out of the insurance plan’s network, and ask the doctor to accept the amount that the insurance plan paid as payment in full.

Just don’t give up, says Butcher. “Mainly it comes down to: If something is denied, you appeal and appeal and appeal.” As the GAO study found, persistence often pays off. [Copyright 2011 Kaiser Health News]

Leave a Reply

12AM to 5AM The Spy

The Spy

An eclectic mix of the Spy's library of more than 10,000 songs curated by Ferris O'Brien.

Listen Live Now!

5AM to 9AM Morning Edition

Morning Edition

For more than two decades, NPR's Morning Edition has prepared listeners for the day ahead with two hours of up-to-the-minute news, background analysis, commentary, and coverage of arts and sports.

View the program guide!

9AM to 10AM The Takeaway

The Takeaway

A fresh alternative in morning news, "The Takeaway" provides a breadth and depth of world, national and regional news coverage that is unprecedented in public media.

View the program guide!

Upcoming Events in your area (Submit your event today!)

Streaming audio and podcasts

Stream KOSU on your smartphone

Phone Streaming

SmartPhone listening options on this page are intended for many iPhones, Blackberries, etc. with low-cost software applications available to listen to our full-time web streams, both News on KOSU-1 and Classical on KOSU-2.

Learn more about our complete range of streaming services

We're perfecting the patient experience - Stillwater Medical Center