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Health Insurance Problems - Out of Network Claims and Bills

How to Avoid Problems Caused by Out-of-Network Claims and Bills

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Updated March 19, 2012

It used to be that we patients could make an appointment with just about any doctor or hospital we wanted to, and not give any thought to whether or not our insurance company would pay for those appointments or hospital stays. However, that is no longer true. As health insurance options and costs become more difficult for patients to deal with, the same is also true for doctors, hospitals, testing facilities, pharmacies and other healthcare providers. As a result, fewer doctors and facilities are willing to work with fewer health insurance companies - and that spells trouble for patients.

It's no longer unusual for a doctor's or other provider's services to not be covered by our insurance plans. Most insurance plans restrict who we can see, or where we can go for medical care by refusing to pay for those services and care. If we see a doctor or other provider that is not covered by insurance - whether or not we intended to do so - it is called "out of network".

Sometimes we make that choice intentionally. Maybe you know your obstetrician is no longer covered by your insurance plan - but you wouldn't let anyone else deliver your baby. You'll pay extra for that out-of-network care because you believe that doctor's services are worth the extra out of pocket cost.

Sometimes we are blindsided by extra bills from an out-of-network provider who we thought was covered, but was not. Your surgeon is part of your insurance company's network, but the radiologist your surgeon works with is not - and you get a bill from the radiologist. Or you go to see the primary care doctor you've seen for years, only to find out when a much higher bill than you expected arrives that your doctor no longer accepts your insurance plan. Or, your insurance reimburses for hospital expenses, but not for a private room - but a private room was the only kind available, so you end up being billed for a private room as if you didn't have insurance.

Perhaps the most frustrating aspect of out-of-network expenses is that there are different pricing structures for insurance companies vs individuals. Examples: The doctor visit that costs your insurance $40 worth of reimbursement will cost you $100 out of your pocket as an out-of-network service. Or the drug that used to cost you a $10 co-pay, and costs your insurer $50, now costs you $120 at the pharmacy because you are no longer part of that network.

What can we patients do about it? There are a few steps we can take to avoid out-of-network costs, or to try to control them:

How to Avoid Out-of-Network Billing

  • Prior to receiving care, don't just ask whether a doctor or service "works with" your insurance. Many doctors and healthcare facilities will tell you that yes, they will "work with" your insurer, even if that work is considered out-of-network. Instead ask whether they are part of your plan's network. And, of course, get the answer in writing whenever possible.


  • Don't assume that anything your doctor orders for you will be covered just because your doctor is covered. Your doctor might order a blood test and send you to a lab in the same building. But that lab may not be covered by your health insurance. Double check every step of the way.

  • If possible, check with your insurer prior to the care, too. Ask your insurer (or go online to the insurer's website to find out) if your plan covers the doctors and services you will need. This may not be easy to uncover in a case like the hospital billing described above, but it's worth a try. And, of course, get the answers in writing whenever possible.

If You Do Receive an Out-of-Network Medical Bill

  • Complain to the insurance company first, and see if you can get them to pay the bills. You may find the description in your policy is fuzzy. Pull out all the stops to make sure you make it very difficult for them to say no.


  • Negotiate those bills. Call the hospital or provider's billing department, tell them your bills are unaffordable, and politely ask them to help you bring them down to a level you can afford. Ask them to at least honor what the insurance company would have paid for them. Ask them to put you on a payment plan, too.


  • If you can't or won't complain to the insurer, or can't or won't negotiate the bills yourself, find a medical billing advocate to help you. They will negotiate on your behalf, will make sure unnecessary and unfair charges are removed, and will set you up on a payment plan with the hospital. You'll have to pay for their services, but you will very likely save far more than you spend due to their knowledge of how the system works.

How to Complain in Hopes of Changing the Increase in Out-of-Network Care

  • Complain loudly and often. Complain to the hospital or provider (AFTER your negotiations are finished.) Complain to your insurer. And complain to both the health insurance department and the attorney general in your state.


  • Be as careful as possible in choosing your health insurance when you are able to make a change. Insurance plans must provide a list of doctors who accept their plans before you commit to their insurance, so you can start there. You can ask your doctor or his or her office manager questions, too.

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