In-network and out-of-network for people with health insurance, those words mean one thing: money. If you dont want to get charged extra, you get your treatment done in-network. It sounds straightforward, but sometimes it doesnt work out that way, even when patients think theyre playing by the rules.
Jeffrey Craig Hopper, a probate attorney in Austin, Texas, knows all about following the rules. Still, accidents happen. Last June he was coaching a Little League practice session when an errant baseball smashed into his face.
His wife Jennifer Hopper remembers rushing to the field.
His eye was swollen shut enough that we werent sure if he could see, she said.
Even in that moment of panic, Jennifer made absolutely sure to drive him to a hospital in Austin that was part of their insurance network.
In the end, Jeffrey was okay. He broke some facial bones around his eye, but they healed and his vision was fine. The family settled the co-payments for the emergency room but was surprised when they later received a separate bill for more than $700 from the emergency department doctor.
Last June, a baseball hit Jeffrey Craig Hopper, a Little League coach in Austin, Texas, in the eye. Hopper and his family were surprised that an out-of-network doctor treated him at an in-network hospital. (Photo by Jennifer Hopper)
It felt kind of random, Jennifer said. How do I know whos going to charge me, and whos not going to? So that was the first question.
Like many patients, the Hoppers assumed that doctors working at an in-network hospital would, of course, be in network.
As it turns out, thats not necessarily true. Emergency room doctors, radiologists and anesthesiologists often dont work for the hospital. They work for themselves, often in large practice groups, and its up to the doctors to sign their own deals with insurance companies.
Many of them dont. In those situations, the doctors can bill the patient for whatever the insurance company wouldnt cover because the care took place outside of the approved network, a practice known as .
I couldnt let that go, it just felt wrong, Jennifer said. Because there was no way out. There was obviously no way we could have avoided the situation, given our emergency.
The , a left-leaning Austin think tank, recently analyzed ER billing by the three biggest insurers in Texas Humana, Blue Cross and United.
Its found that in over half of Humanas Texas hospitals, none of the ER doctors was actually in Humanas network. For United, this occurred at just under half of the hospitals and for Blue Cross, at about a fifth.
The reports author, Stacey Pogue, said balance billing is unfair to patients.
No other consumer services are sold to us this way, she said. It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately. And some of them will negotiate with you on the price, and some of them will accept coupons, and the others dont.
The Texas insurance industry has said it would like ER doctors to join their networks, but it cant force them to.
The ER doctors that insurance companies often dont pay them enough when they join networks.
The economics of ERs are complex, explained Dr. Bruce Moskow, president of the .
In an emergency department, we see everyone and were not even legally allowed to ask if theyre going to pay their bill, Moskow said. Large numbers of people pay nothing.
There is a in Texas for some of these out-of-network bills, but its only for certain types of insurance and certain situations.
Some states have tried to tackle the problem in different ways. In California, ER doctors cant send a separate bill to HMO patients. In New York, a newly-passed law requires out-of-network doctors and insurers to hash out payment on their own, and leave patients out of it.
Texas insurers have indicated theyd be receptive to more changes, such as expanding the mediation process. Its currently restricted to balance bills over $1,000 and certain types of PPOs.
Just get the consumer out of it, said Jamie Dudensing, the CEO of . If you just leave it between the health plan and the physician, the consumers not dealing with this issue. Let us work this out through the private market.
Jennifer Hopper said she spent weeks appealing the physicians bill, going back and forth between the doctor and the insurance carrier. Eventually she filed a complaint with state regulators. After that, her insurer ended up paying part of the physicians bill.
People are typically advised to do their homework ahead of time and know whos in their network and who isnt. But Pogue said that isnt always possible, especially in an emergency.
If youre wheeled into the emergency room door, you cant ask the emergency room physician who runs up to stabilize you Are you in network or out-of-network? she said. That physician needs to be concentrating at that point on giving you life-saving care, not rattling off the list of insurance companies that he or she contracts with.
Hopper has tried to do her homework by figuring out where to go for a possible future ER visit. Online, she searched her health plan to find ER doctors who were in-network. But she found less than five at the hospitals her plan used in Austin. She doubts the odds of getting those doctors the next time she or a family member needs care.
So the reality is, all the transparency in the world doesnt change the fact that knowing everything, I could not be sure I would get a different outcome, she said.
This story is part of a reporting partnership that includes , and Kaiser Health News.
