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How to battle out-of-network billing

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An Arizona man who received emergency treatment at a hospital that was in his insurance network received a bill for nearly $1,900 because the doctors were out-of-network. (Source: 3TV) An Arizona man who received emergency treatment at a hospital that was in his insurance network received a bill for nearly $1,900 because the doctors were out-of-network. (Source: 3TV)
"I didn't know doctors could work at an in-network hospital and be out-of-network," Brett Hayden said. (Source: 3TV) "I didn't know doctors could work at an in-network hospital and be out-of-network," Brett Hayden said. (Source: 3TV)
Dr. Victor Zachm, one of the doctors who treated Hayden, says it's very common for doctors who are considered out-of-network to be practicing in an in-network facility. (Source: 3TV) Dr. Victor Zachm, one of the doctors who treated Hayden, says it's very common for doctors who are considered out-of-network to be practicing in an in-network facility. (Source: 3TV)
(3 ON YOUR SIDE) -

Brett Hayden loves to travel and has been all over the world. 

"I just like to see other parts of the country and experience different ways of living and different cultures," he explained.

But a recent health scare has put a temporary hold on Hayden's traveling.

"I was at work one day and I felt something," he recalled. "I couldn't swallow. I was having a hard time swallowing and I felt like something strange happen in my brain."

Hayden went to the emergency room at John C. Lincoln Hospital, which his insurance carrier considers in-network, and he was admitted for high blood pressure and stroke.  

Fortunately, Hayden fully recovered but one doctor's bill for nearly $1,900 concerns him because it was denied by his insurance carrier.

Why? Because Hayden doesn't have out-of-network coverage.

"So I called the doctor’s office and they told me that I needed to call the insurance company because the insurance company needed to do something about paying them," Hayden explained.

But according to Hayden, Blue Cross Blue Shield Premera wouldn’t pay that $1,900 bill because even though the hospital he went to was in-network, the doctors were out-of-network. 

"I didn't know doctors could work at an in-network hospital and be out-of-network," Hayden said.

Dr. Victor Zach, the director of the Stroke Neurocritical Care at John C. Lincoln, is one of the doctors who treated Hayden. He says it's very common for doctors who are considered out-of-network to be practicing in an in-network facility for a few reasons. 

RELATED: Phoenix woman stuck with $6,312 'out-of-network' medical bill (Oct. 27, 2015)

"There are many, many insurance companies and it's impossible to be contracted with every insurance company out there," he said.

Complicating the issue, according to Zach, is that insurance companies frequently refuse to pay a doctor's regular charge and instead prefer to pay at a reduced rate if that doctor is contracted with them. That means there's no financial incentive for doctors to contract with insurance companies.

Zach says the insurance industry should consider paying at a higher rate to avoid these pitfalls.

"The doctor and the patient are on the same team and the insurance company is a secondary member of that relationship," he said.

Zach says that in any case like this, the patient should call and appeal the decision with the insurance company and ask for the bill to be paid. If that doesn't work he said most doctors, including him, can negotiate to a smaller amount. 

In Hayden's case, Zach reduced the bill by almost 75 percent.  And after we contacted Blue Cross Blue Shield, Hayden said the company agreed to pay that bill in full.  

"It's very important to get this message out so patients know that they aren't alone, so they don't feel like they're just stuck," Zach said.

A big thank you to Zach for taking the time to explain the process from a side we rarely get to hear from and also for helping Hayden with his bill. 

Here again are some tips Zach recommends if you find yourself in a similar billing situation.

1. When shopping for health insurance, pay attention to out-of-network coverage options. Emergencies happen unexpectedly.  

2. Chose a deductible that you can handle; save up for a rainy day. Chances of encountering out-of-network providers are high in an emergency.

3. Work with the provider's billing department and keep frequent, professional lines of communication open.

4. Complete the appeals process with your insurance carrier - 90 percent success rate.  The carrier may at least pay in-network rates which will reduce the bill.

5.  If the insurance still denies the appeal, write a letter of financial hardship to the provider. Most can offer a discount or a 0 percent interest payment plan.

In an addition Blue Cross Blue Shield Premera offered the following statement and advice: 

I understand your desire to bring attention to circumstances when someone receives care at an in-network hospital or clinic and inadvertently gets treated by another doctor or specialist who is not part of the patient's network.The surprise bill, also known as 'balance billing' continues to be a problem in the healthcare industry. We are working on this issue daily and have a team at Premera dedicated to finding ways we can make this process better for our customers and reduce or even eliminate surprised balance billing.

Patients who have received these bills can take action to try to reduce or in some cases, eliminate the balance billing amount.

  • Call the provider sending you the bill and ask them to take the amount your insurance company is offering or negotiate the bill amount
  • In some situations, we automatically provide coverage at the in-network level and in the case of some specialty treatments, the patient can contact our customer service representatives and file an appeal. The representatives can walk the member through the process and the member will get a response in writing

Premera has taken a number of steps to reduce or even eliminate surprises including:

  • We notify customers when a provider is out of network.  For example, we have taken a number of steps to inform our members not only letting them know that a specific hospital or group of doctors are no longer in network, but we also  give them alternatives that are in network.
  • We send notifications to customers when an out of network provider calls us to check benefits to let them understand the impact to them of out-of-network care and to help them find an in network doctor.
  • We make every effort to ensure that patients have the best and most up to date information available to them to help them avoid surprise billing, including hospitals letting them know ahead of time if anyone in the chain of care such as a laboratory or anesthesiologists are out of network and health plans letting them know when doctors and hospitals are out of network.

Copyright 2016 KTVK (KPHO Broadcasting Corporation). All rights reserved.


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Gary HarperGary Harper is the senior consumer and investigative reporter for 3 On Your Side at KTVK-TV.

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Gary Harper
3 On Your Side

With more than 20 years of television experience, Gary has established himself as a leader in the industry when it comes to assisting viewers and resolving their consumer-related issues. His passion and enthusiasm have helped him earn an Emmy for Best Consumer Reporter from the National Academy of Television Arts and Sciences. He’s also garnered several Emmy nominations

He has negotiated resolutions with companies of all sizes, including some of the biggest corporations in the nation.

Gary has successfully recouped more than $1 million for viewers around the state, making 3 On Your Side one of the most popular segments on KTVK and the station's Web site.

He's best known for investigating and confronting unscrupulous contractors. In fact, many of his news reports have led to police investigations and jail time for those who were caught. Viewers, as well as the companies and people he investigates, regard him as consistently being thorough and fair.

Gary has been with KTVK-TV since 1997. Prior to his arrival in Phoenix, he worked for WZZM-TV in Grand Rapids, Michigan, where he was as an anchor and reporter.

Gary is from Chicago, but launched his television career in Lubbock, Texas, after earning a broadcast journalism degree from Texas Tech University. Following his graduation, he was quickly hired by KLBK-TV in Lubbock, where he enterprised and broke numerous exclusive reports. His aggressive reporting in Texas helped garner him Best Reporter by the Associated Press.

Gary has been married since 1994 and is the proud father of two sons. When he's not helping viewers, Gary is busy catching up on his favorite college and professional football teams as well as cheering on his beloved Texas Tech Red Raiders.

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