Dear Tom and Alan:
I recently had a bill for the hospital, surgery, etc., at Queen of the Valley.
First, we have a great hospital staff here in Napa, and I am very happy with the attention given me. Thanks to all.
Here’s my beef. According to my insurance company, the Queen is part of their network, so is my surgeon. My anesthesiologist was not.
How can that be?
Of course, I didn’t even think of asking before the cutting.
Wow, I am shocked at how little my insurance company paid for the out-of-network doctor. Can you explain what happened?
I am now very aware of “in” and “out” of network…after the fact.
Full of Bills
Tom: Yes, Bill, many of us have been caught in the out-of-network/out-of-pocket expense. After my least favorite medical procedure earlier this year, I received a separate billing from my anesthesiologist as well.
The situation is that not every doctor needs to contract with every insurance carrier. The Queen does not police this as the doctors’ rotations vary day by day.
The fix is to check that all doctors working on you are contracted and request the particular day the contracted providers are in rotation.
Al: Quite a few years ago, at UCSF, I actually met the anesthesiologist well before the surgery and confirmed he was in network. On the day of the procedure, he was called away for a family emergency. You guessed it — his replacement was out-of-network.
Tom: FYI, this is also true of other providers. For example, my in-network doctor sent a sample to a laboratory that was out-of-network.
Many, if not most, emergency room doctors are not contracted with any carrier, although the facility they work at is in-network.
You also might encounter this problem with ambulance services. To date, the only recourse was to file an appeal or grievance with the insurance company if no provider in your area was contracted.
Al: On Sept. 23, Gov. Brown signed Assembly Bill 72, which, according to the bill’s author, will prevent “surprise bills” because of a “…complicated and unfair billing system.”
San Francisco Chronicle writer Victoria Colliver stated: “The surprise medical bill legislation is designed to prevent patients, many of whom checked in advance to make sure their doctor and hospital were in their insurer’s list of contracted providers, from getting hit with out-or-network charges after undergoing a procedure…”
Tom: This law requires the insurer to pay the out-of-network provider at the average contracted rate for that service or at 125 percent of the Medicare rate, whichever is greater. The out-of-network amount will go toward the insured’s out-of-pocket maximum.
No immediate relief, the law goes into effect next July.