It's a common problem that could become worse under the Affordable Care Act: Patients visit an in-network hospital but are charged thousands of dollars because the doctors who treated them work for the hospital but are considered out-of-network providers.
Patients think when they hand over their insurance cards at the hospital registration desk that if the organization accepts the insurance they are covered for all treatment they receive. However, many doctors who work in a hospital don't work for the hospital and aren't required to join the same insurance networks as the organization, Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told The New York Times.
Patients don't think to ask and the referring doctors don't think to check the patients' insurance. In some cases, patients never see the out-of-network providers, for instance if an X-ray is sent to a radiologist or their tissue is sent to a pathologist. Patients won't know the name of the doctor until they receive the bill, Pollitz said.
These cases may skyrocket under the Affordable Care Act, according to the NYT. While the ACA does cap what patients must spend out of pocket when they use providers within their plan's network, except for limited protections, it doesn't cover providers outside the network. Out-of-network providers will accept insurance payments according to a set schedule but can send patients the balance to cover the rest of the bill. And those bills can be enormous.
"This is not an issue that the Affordable Care Act fixes," Timothy S. Jost, a professor at the Washington and Lee University School of Law and expert on healthcare laws, told the NYT. "It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do."
And since most of the state-run exchanges don't have provider directories or search tools on their websites, consumers can't check to see which doctors and hospitals a plan's network includes. Many doctors don't even know if they are covered under a particular plan, FiercePracticeManagement previously reported.
And in New York, none of the medical plans listed in the New York Health Exchange for individuals offer out-of-network coverage. Therefore, a patient who sees a doctor not included in their plan's network will have to pay 100 percent of the cost, the New York Post reports. New York officials and insurance companies told the Post the decision to not provide out-of-network coverage is because their priority is affordable plans, not choice.