It’s important to communicate to employees that they can be balanced billed if they go to an out-of-network provider – and that these charges are not subject to the insurance carrier’s negotiated discounts that apply in-network. Make sure to keep your broker in the loop about these issues as employees come to you with questions or complaints that they can’t access in-network care to prevent this scenario from befalling your team.

Thoughts from Allison Hasday

I was watching a national news network not too long ago when yet another story about egregious health insurance billing came up. The piece related the tale of a Montana insurance plan participant who was billed a whopping $540,842 for 14 weeks of dialysis care at an out-of-network facility. The participant was following his provider’s advice to get immediate dialysis treatment for his newly diagnosed kidney failure. There were no in-network dialysis clinics in his state and he had to use an out-of-network facility.

The dialysis company’s justification for these ludicrously high charges was that the private health insurance market subsidizes the lack of money they make off of negotiated Medicare rates and the uninsured, which often pay significantly less than the cost of services. Subsequently, private health plan participants who go out-of-network can be subject to a nasty balance-billing surprise, and while some states have protections in place against surprise balance billing, these are limited by federal law.

Most of our clients don’t have an issue finding in-network care but it has the potential to be very problematic if gone unaddressed. Typically, alternative arrangements can be made when an in-network provider is not available to an employee, and their provider will be treated as in-network for a service or series of treatments. This applies if the employee truly cannot find a provider – not that they just don’t like any of the in-network choices in their area. Often, the insurance company or employer will agree to pay for the cost of a service if they feel that no alternative arrangements could have been made.

Allison Hasday

Assistant Vice President, Employee Benefits - New York, NY