Select Page

How can I try to avoid charges for unexpected and/or unnecessary out of network providers or excluded benefits?

Keep in mind that your provider(s) may require you to sign an Informed Consent form stating that they may do additional procedures or include additional physicians at some point during your stay without being obliged to discuss their decision to do so with you or your advocate. Also keep in mind that out of network providers and excluded benefits are billed at their Charge Master or Provider Charge rates, which are often several to many times the reasonable and customary rates. That means that you may be planning on a hospital stay that financially obligates you to pay whatever remains on your deductible (usually several hundred to several thousand dollars), but you’re still exposed for any excluded benefits or out of network providers, which could add tens of thousands or even hundreds of thousands of dollars in debt.

There are several scenarios where unnecessary or unexpected charges for excluded benefits or out of network providers may creep in.  And be aware that The Cost Beast absolutely thrives on Scenarios 2 and 3:

Scenario #1: A bona fide emergency while you’re under anesthesia.

This is why the language is in the Informed Consent in the first place. If you’re under, and something goes seriously wrong, your surgical team is going to do whatever they have to do to stabilize and save you, and they’re not going to worry about how it’s paid for. Nor should they, under those circumstances.  Thank them when you wake up.

Unfortunately, there is no way to avoid a bona fide emergency.  This is unexpected, but it’s definitely necessary.  That’s why it’s an emergency.


Scenario #2: The discretionary procedure or consult.

This happens when an additional procedure or consult takes place under non-emergency circumstances. An example would be a post-surgical consult. Since the culture amongst physicians is often such that they aren’t necessarily aware of your insurance coverage details, or whether insurance will be paying or you will, or how much, they tend to treat all of their patients the same and often don’t hesitate to do additional procedures or call in a colleague for a consult. So this scenario is not at all uncommon.

Avoiding discretionary procedures or consults:  Your best chances of avoiding this scenario is in the conversation you have with your lead provider during your pre-admission checklist (see details under Step 4 of the section on Estimating Costs for Inpatient Stays.  Note that the downloadable versions of the checklist are more detailed).

Make it clear to them that you chose them because you trust them to help you achieve the best possible clinical outcome based on your treatment goals.   But also let them know you have financially prepared to meet your obligations (deductible, co-pays, etc) based on receiving included benefits from in network providers. Let them know clearly that you’re asking that they consult with you or your advocate before doing any unplanned procedures or involving any unscheduled physicians or other specialists, and if they’re recommending excluded benefits or out of network providers, you will be paying out of pocket and they’re likely to be very, very expensive. Don’t be afraid to tell them that while you’re most concerned about meeting your treatment goals, you’re also concerned that the casual use of excluded benefits or out of network providers – especially when there are viable alternative included benefits or in network providers or the value of their use isn’t clear – since they could potentially result in financial ruin for you. Ask them flat out to help manage your financial risk.

Scenario #3: Mistakes, over billing, and billing practices of ‘questionable’ validity.

The documented error rate on hospital bills has been measured as high as 25%. And unfortunately, bills can come from several different providers or departments within the hospital and can be so complicated that it’s difficult for a patient or their family to even reconcile the line items with services and products actually received, so it can be difficult to detect errors. And even more unfortunately, some hospitals deliberately bill for ‘facility fees’ (a blanket fee for the use of the facility itself) or they bill individual line items for things like aspirin, the tiny cup the aspirin comes in, the nurses time for administering the aspirin, gauze pads, facial tissues, or even the lights. And they do so not at or close to cost, but at outrageously marked up rates. When an insurance plan negotiates for a hospital stay, they usually negotiate an all-inclusive fee for the use of a room by type (such as an Operating, ICU, recovery or normal room) and by the day or by the hour. If the hospital bills the insurance company for the room, but then also bills facility fees and/or individual line items for what the insurance company considers part of the room (like minor disposables), then the insurance company considers those charges to be excluded benefits and passes them on to the patient. The hospital may defend this as a ‘normal business practice’, but most people, especially those receiving the bills, would consider this to be double dipping and ethically questionable at best.

Avoiding mistakes, over billing, and billing practices of ‘questionable’ validity.  Your best chances for avoiding mistakes and over billing is to commit the energy to reviewing and understanding your EOB.  Start by doing your best to predict what your costs should be (see Steps 6, 7, and 10 in the Section on Estimating Costs for Inpatient Stays) in preparation for reviewing your EOB in detail after your discharge (Step 14).  Note that the downloadable versions of the checklist are more detailed.


Next:  Tips on what to do if you receive a bill directly from a lab, imaging center, or other diagnostic service provider.


Remember:  We coach, support, educate, and empower.  We illuminate options you may not have known you had.  But we don't decide what's right for you in your unique circumstances; only you can do that.  And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.