Obamacare Q&A: How to fight an unexpected bill

CHCF Center for Health ReportingJune 23, 2014 

Emily Bazar answers reader questions about Obamacare, the Affordable Care Act, for the CHCF Center for Health Reporting.

CHCF CENTER FOR HEALTH REPORTING

Do your homework.

That's the advice that health insurance companies have long given. They tell you to verify whether your doctor or hospital is in network before you head to your appointments. If you don't, you risk a hefty bill for visiting an uncovered provider.

But in the age of Obamacare, "doing your homework" has gotten exponentially more complicated. As I have explained in two recent columns, many insurers have significantly limited the number of participating doctors and hospitals.

To make matters worse, provider lists have been rife with inaccuracies and it can be near impossible to get through on insurers' jammed customer service lines. Some doctors themselves don't even know which plans they're on.

Many of you are heroically trying to confirm your providers' status. I'm sorry to say that some of you will nevertheless receive unexpected bills in the mail saying the doctor or hospital you visited wasn't in network after all.

It's already starting, and I predict these bills will become a major problem as more of you seek care.

Today, I'll give you some tips about how to fight out-of-network bills that you don't believe you're responsible for.

Question: I purchased an Anthem Blue Cross PPO plan. Before Jan. 1, I checked Anthem's website for a doctor in network and called the clinic to double-check. When I went to the appointment, I was sent away because the clinic informed me they were not part of the network. ... I called another doctor's office twice before I went to see him, and both times I was told they were in the network. I kept my appointment, then I received the bill and an Explanation of Benefits from Anthem that indicated the doctor was not in the network.

How can people protect themselves from incidents like this?

Answer: This question comes from Libby Higgs of Modesto, a retired human resources manager. You know, the kind of person who likes to wade through details to hunt down answers.

But even Libby seems to have met her match against Obamacare's " narrow networks."

Her unexpected bill came to $333 and she protested. Because of the confusion related to this doctor's status, Anthem agreed to reprocess claims from that doctor through March 31 as if he were in network. That brought her bill down to $108.

Her sister, who was referred to a neurologist by her primary care physician, wasn't as lucky. The neurologist wasn't in network after all, and now her sister faces a $1,000 bill.

"Before, it was pretty set in stone that if a provider said they were in network, they usually were. There wasn't a whole lot of doubt," Libby says.

Not anymore.

Anthem says it has worked hard to increase the accuracy of its provider finder tool on its website since the beginning of the year. Spokesman Darrel Ng says Anthem has asked every medical group for a new roster of doctors who participate in its individual and family plans.

But Libby still questions Anthem's accuracy. She went to the plan's website on May 31 to search for a podiatrist.

"If you just glance at this, it looks like there are 19 podiatrists in my area, and there really are not," she says.

If you, like Libby, do your homework and still get billed for going out of network, follow these steps:

• Call the plan's customer service number and ask to get the bill fixed.

• If your complaint isn't resolved quickly, file a grievance with your plan. The law says that plans must give you at least 180 days to do so, says Marta Green of the state Department of Managed Health Care (DMHC).

• In most cases, the plan has 30 days to address your grievance, she says. If you're not satisfied with the response, call the DMHC Help Center at (888) 466-2219. Each complaint is handled on a case-by-case basis, so that (hopefully) means yours will get some personal attention.

Along the way, build a paper trail. If an insurer's website tells you a doctor is in network, take a screen shot and save it.

If you talk to customer service agents, keep a log. Note the time and date of the calls and ask for each agent's name.

Once again, beware of relying on your doctor alone to confirm network status because your financial contract is with the insurance company. If the doctor is wrong, your health plan may not be willing to adjust how much it pays.

Ng of Anthem confirms this: "Just like any other business, the party who makes the error is responsible."

(Even if you relied on your doctor alone, you should still call DMHC's Help Center, Green says. She can't promise a positive outcome to your complaint, she says, "but we would like to try to help.")

I asked Libby what she plans to do differently for future doctor's appointments, given her disappointing first experience.

"I'm trying not to go to any doctors," she says. "I'm really hoping that by next year, they will have this straightened out and that the doctors I really want to see will be part of Anthem."

Emily Bazar is a reporter with the California Health Care Foundation's Center for Health Reporting. She can be reached at AskEmily@usc.edu. The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.

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