Exorbitant Out-of-Network Charges Detailed in New Report

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medical-billing-advocate_143305306It seems that every week, the media reports more instances of patients being billed an exorbitant amount by an out-of-network provider, which likely came via a surprise medical bill. Far and wide, out-of-network providers are seemingly billing any amount they wish for their services.

AHIP – America’s Health Insurance Plans – put out a report that details some of the exorbitant amounts that out-of-network providers charge. The report compared the average cost of out-of-network charges for certain services and procedures to the amount that Medicare pays for the same services and procedures. Below is a sample of some of the report’s findings:

  • Medicare pays $176 for a high-severity emergency room visit, but out-of-network providers charge an average of $971 – 552% more than what Medicare pays.
  • Out-of-network providers charge an average of $2,929 for an MRI of the brain; Medicare pays $405.
  • Out-of-network providers charge an average of 1,023% more for a cervical/thoracic spine injection – Medicare pays $113, out-of-network providers charge an average of $1,152.

The report also offers specialized state reports that warn of some of the highest markups for specific services in that state, according to data from AHIP. For instance, in Virginia, you should be absolutely certain that an in-network provider is performing your ultrasound for a biopsy. In Virginia, the average markup of this service is 500% by out-of-network providers. An hour of chemotherapy by an out-of-network provider averaged more than 400% of the Medicare fee.

Your best defense against surprise out-of-network provider bills is to make sure that the facility staff knows that you are not willing to have any physician see you who is not an in-network physician. This should include staff in all departments, including anesthesiologists and lab and radiology staff. Ask if all the providers involved in your care are in your network. Contact your insurer and make certain that the doctor you are being referred to is in your network. Don’t just check on the insurance website; data can change and might not be updated in a timely manner. Talk to a health insurance representative and write down their name and the date and time that you talked to them.

If your primary care physician refers you to another doctor, remind your physician of your health insurance so that he or she will refer you to another in-network physician.

If given enough warning, it’s a good idea to go to the facility and have an appropriate member of staff sign a document stating that only in-network staff will tend to your care.

If you are being billed by an out-of-network provider when you were being seen at an in-network facility, call Medical Billing Advocates of America at 855-203-7058. Our research department will ensure that you only pay True and Accurate charges and Fair and Reasonable prices on your medical bills.


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One response to “Exorbitant Out-of-Network Charges Detailed in New Report”

  1. Nancy Viola says:

    I am a social worker with a non-profit MLTC (Managed Long Term Care) plan in NYC. Much of my time is spent assisting members with medical bills they receive but are not personally responsible for since they are dually covered by both Medicare and Medicaid. Do you charge for your services to individuals?

    Also, is it legal in New York State that the plan I work for no longer makes a print version of its member directory available to each enrollee unless requested, and each request must be reviewed by “a committee” prior to the directory being mailed out?