Out-of-network doctors bring unexpected bills

McClatchy Newspapers

FORT WORTH, Texas — Phil Heidelberger did what savvy patients are supposed to do.

When he needed a cardiac procedure in 2007, the semiretired Fort Worth salesman confirmed ahead of time that his doctor and the hospital belonged to his health insurer’s network.

That way, he’d be sure to avoid the extra expense that comes with treatment at outside facilities.

Here’s what Heidelberger didn’t know until it was too late: The anesthesiologist who assisted on his case didn’t have a contract with the health plan. It’s a distinction that could cost him a whopping $1,005.

What Heidelberger encountered was an all-too-common practice known as “balance billing,” which has drawn complaints for years from hospital patients, lawmakers and regulators nationwide.

It happens when anesthesiologists, pathologists, radiologists and emergency-room physicians at a hospital on a health plan’s network aren’t on the network.

Those out-of-network doctors, who don’t have an agreement with the insurer for discounted fees, can demand full price.

Then, insurers can determine what portion of the bill they’re willing to pay. And the physicians can collect the remainder of the tab from patients.

Those bills, which can be far more expensive than patients would have paid to in-network specialists, are the target of scrutiny in various quarters.

New York officials in January reached a $50 million settlement with UnitedHealth Group, after allegations that a company subsidiary manipulated reimbursement rates for out-of-network healthcare providers.

Several medical societies joined forces this month to sue health insurers Aetna and Cigna over their out-of-network rates. Those two lawsuits raise issues similar to those in the New York case, and both insurers said they intend to defend themselves vigorously.

An anesthesiologist at the hospital spent a few minutes giving Heidelberger a local anesthetic, he said. The anesthesiologist had set a fee of $2,020 for his services, and the insurer had paid only the amount it deemed fair for an out-of-network doctor — $1,015. So, the doctor turned to Heidelberger in October for the remainder of the bill.

Heidelberger has refused to pay. He contends that he should have been warned that the anesthesiologist was a costly out-of-network provider.