Out-of-Network Bills for In-Network Health Care

When an uninsured or insured person with a low coverage rate receives treatment at a hospital or clinic, you may be asked to pay full medical expenses, regardless of your ability to pay. Therefore, many people have debts due to high medical expenses and going bankrupt. To prevent this, it is important to meet directly with the financial counselor of each hospital to discuss whether it is possible to reduce medical expenses and take out insurance, including public medical insurance.

To reduce medical expenses in the hospital, please refer to the H+H option that you can have a medical examination at a rate according to your income without insurance. Also, there are assistance programs at New York-Presbyterian Hospital. Please call New York-Presbyterian/Columbia University Medical Center at (212)-632-7440, NewYork-Presbyterian/Weill Cornell Medical Center at (866)-252-0101 for more information.

When an out-of-network doctor charges many medical expenses at an in-network hospital.

Despite being insured at an in-network hospital, you may be charged many medical expenses from an out-of-network doctor. Primarily in cases such as surgery, these out-of-network doctors include radiologists, anesthesiologists, pathologists, and surgeons who assist in-network surgeons.

Some insurance plans do not cover out-of-network medical expenses and must pay their own expenses. Also, some plans only cover a part of the out-of-network medical expenses, but you still have to pay the difference between the amount charged by the doctor. This is called a “Balance Bill.”

The best way to prevent this is to consult with your doctor before scheduling a surgery to ensure that all doctors are in-network. If you already have a large medical bill, you can negotiate with your out-of-network doctor to reduce your medical bill.

In the case of an emergency, including an accident or a heart attack, there is no room to choose a hospital. It is usually transported to the nearest hospital. When the condition is settled, it is usually transported to an in-network medical institution. However, it must be the “medical emergency” defined below. In these cases, most plans cover emergency care, regardless of out-of-network. Contact your insurance company for more information on emergency coverage and more.

“A condition with acute symptoms of sufficient severity (including severe pain) that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in–(1) placing the health of the individual (or an unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part.”

So what do you do when you receive a medical bill from an out-of-network doctor?

• If you are in emergency care, please contact your insurance company and tell them that you have a medical bill from an out-of-network doctor for emergency treatment. Depending on the plan, medical expenses may be covered in full.
• Doctors have no obligation to reduce, but they may be able to reduce. Contact the out-of-network doctor who made the medical bill and try to negotiate if they can reduce it. You can also have agencies that negotiate medical bills like Medical Bill Mediation, Medical Cost Advocate, etc., act on your behalf and ask your doctor to reduce it; however, there is no guarantee.
• Find out the out-of-network reimbursement rates for your insurance plan and make a claim using your insurance company’s claim form.
• If the insurance company denied your claim, please contact them first to find out why they denied it. There may be a mistake on the claim.
• Appeal if you receive a Denial Letter from the insurance company. In many cases, the Denial Letter has instructions on how to appeal. Follow the instruction to create an appeal letter and mail it to the insurance company. (Appeal letter sample by Community Health Advocates)
• Complain to New York State Financial Services with all the documents printed out at the time of appeal.

＊Please copy all the documents mailed to the insurance company, indicate the date you mailed them, and keep it as your record. Some insurance companies may have set an appealing period, so please do it immediately.

For more information：
Out-of-Network DIY Appeal Packet
Community Health Advocates