Out of Network Medical Costs Can Add Up Quickly

Oakland, CAWhen it comes to understanding health insurance, some of the most complex issues may revolve around out of network medical expenses. Out of network charges can be costly and they can be unexpected. That is because many people may not be entirely clear on what constitutes out of network medical care. Even within one facility, various procedures may be considered out of network services, and can carry high fees.

According to an article at the San Diego News Network, the issue of out of network care does not necessarily end with whether or not a hospital is covered by a health insurance network. In fact, a hospital may be in network, but there it may be that some doctor's visits and other services are not covered by your insurance. This means that it is up to the patient prior to any hospital visits to ask questions about which doctor's visits are covered and which are not.

Such an issue was reported in the St. Joe News, which related the story of Steve and Ruth Myers, who went to an in network hospital only to find out that not all of their expenses were covered. Why? Because some services, such as emergency services, are actually contracted out and the company that the work is contracted to is not required to accept the same insurance policies that the hospital does. The same is true of some radiology and pathology services.

As far as surprises go, receiving a high bill for medical care you thought was covered is right up there. Had you known that the procedure was not entirely covered, or that not all services at the hospital were covered, you may have gone with a different insurance provider.

However, even though it may seem that fighting the insurance company is an impossible task, there is a tiny bit of light in the seemingly ongoing battle between patients and health insurance companies.

Recently, an insurance company, Government Employees Health Association (GEHA) reversed an earlier decision and let a 5 year old girl receive chemotherapy at an out of network hospital. The problem, according to an Associated Press article, was that GEHA had reportedly told the Erica Schneider's family that she would have to travel from her home in Reno, Nevada, to Oakland, California, for her weekly chemotherapy. That would have meant a weekly 400 mile drive for Erica and her family—when the Reno hospital she wanted to go to was only 15 minutes away.

The reason Erica's family wanted to go to the Reno hospital was that Erica's oncologists actually make weekly trips from Oakland to the Reno hospital to provide other pediatric cancer patients with treatment. GEHA had reportedly told the girl's family that if they were to use the local hospital, they would have to pay up to $7,000 annually—a cost the family could not afford.

"The money we already have to pay out of pocket is already more than we can afford," Erica's mom said. "Saying that it is only $2,000 a year more [than the $5,000 in network fee cap]—it might as well be $200,000 a year more. It's already more than we have."

The article noted that many insurance companies whose coverage includes the other main hospital in Reno, Saint Mary's Regional Medical Center, allow a waiver in situations like this because Saint Mary's does not have an intensive care unit for pediatric cancer patients. However, GEHA was reportedly unwilling to follow suit, initially. Following the release of the Associated Press article, GEHA said it would negotiate an agreement with the local medical center so the girl could receive her treatment in Reno.

Sometimes, issues with medical care billing can be dealt with in a few phone calls to the right people. However, some issues with billing are more serious than that, and they may require the help of an experienced lawyer to sort through and determine whether or not legal action should be taken.