Don’t get charged for out-of-network providers

A $25,421 bill a knee replacement?

Imagine this.  You have insurance through Medicare (either Original Medicare or Advantage) and you undergo a successful knee replacement. 

3 weeks later, you get a bill in the mail for $25,421 (YES, 25 GRAND!). 

Turns out, both the surgeon who was assisting and the anesthesiologist were not in your network, so they billed out of network charges. 

You feel cheated.  You did your homework and knew that your primary surgeon was in the network.  So was the hospital. 

However, you’re stuck with this giant bill.    What do you do and how do you prevent this from happening?

You have to be your own advocate. 

Unfortunately, the days of “leaving it up to the doctor and forget-about-it” are over.

Depending on the type of Medicare plan you have, there may be a higher risk of you encountering out of network providers.

Original Medicare + a Medicare Supplemental Plan

With Original Medicare, you typically have access to any provider or hospital in the country that takes Medicare.  However, you’ll have to make sure the providers take Medicare.  More and more providers are leaving Medicare or health insurance all together and going towards a cash only basis.

Medicare Advantage

Advantage plans typically have a narrow network, so you’re more likely to run into issues where only one provider in the room is in the network.  If you have an Advantage plan, take extra precautions to make sure that ALL of your providers are in the network.

So how do you check if all your providers are in the network?

If you’re undergoing a procedure, ask your provider or a case manager who will be in the room and whether they take your insurance.  Remember that different plans from the same insurance company can have different networks.  Make sure all the providers take your specific plan.  Also make sure that the numerous providers following up with you in the hospital are also part of the network.  Typically a care coordinator will be able to work with you one-on-one to make sure you are covered. 

What if you get a big bill and can’t pay?

Some money today is better than no money ever.  Most providers are willing to work with patients to set up a payment plan or a discounted one-time cost if you’re not able to pay your bills.

What if it’s an emergency?

Typically, all emergencies are covered as if they are in network.  In these cases, you won’t have an issue with networks.

Unfortunately, narrow networks and large out of pocket bills are systematic issues.   Until we can fix them on a national level, you’ll have to be your own advocate.  Yes it requires checking and double-checking, but the price of research will certainly be lower than your out-of-network bill. 

Johnny Luo M.D.Comment