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Balance Billing for Out-of-Network Charges at In-Network Facilities Investigation

Have you been treated at an in-network hospital or emergency room that accepts your insurance, only to receive a surprise bill from out-of-network personnel or services? Have you presented your insurance card, paid your deductible, coinsurance or copayment, and then still received a bill for thousands of dollars that you had no idea you would owe?

We’re investigating the practice called “balance billing.”

It’s sometimes legal and sometimes not. But it’s causing financial pain to people across the country who believed that, because they went to a medical facility that accepted their insurance, all personnel and services would be covered. Unfortunately, this is not true.

Balance billing occurs when out-of-network personnel at an in-network facility refuse to accept the network’s “regular and customary” amount for the services they perform. Since the person has no agreement with the network, they may charge whatever they want—and you will be on the hook to pay the difference.

Consider the case of the Hamilton family in Falls Church, Virginia. Teenage son Zack was playing baseball when an inside pitch ricocheted off his bat and hit him in the face. His parents took him to the emergency room of a hospital that accepted their insurance. An on-call plastic surgeon was available to treat his broken nose.

A few weeks later, the Hamiltons received a bill for $34,000. The hospital was in-network, but the plastic surgeon was out-of-network. He had no agreement with the insurer. The $34,000 was the difference between what the insurer was willing to pay for Zack’s treatment and what the plastic surgeon was willing to accept.

The Hamiltons had no idea that an in-network hospital would have out-of-network personnel working there. They had no idea that they would be liable to pay whatever the out-of-network person wanted to charge. (Even if they had been told at the hospital, would it have been feasible to put their bloody-faced, injured son back in the car and drive to another in-network hospital—where the same thing might occur?)

Plastic surgeons are not the only personnel or provider who might be out-of-network at an in-network hospital. Anesthesiologists, pathologists, intensive care specialists, ER doctors, ambulance companies, providers of wheelchairs and other equipment, laboratories, and many other parties may not be covered by the same insurance agreements as the hospitals or emergency rooms they serve.

Some states have laws that attempt to limit balance billing practices, but many provide little protection or none at all. And those laws apply only to state-regulated health plans. Self-insurance plans, like those provided by large employers, are regulated under federal laws. It’s difficult for individuals to know what is legal and what is illegal or simply excessive.

We’re investigating to see if a class action might help.

If you were treated at an in-network facility covered by your insurance and received a balance bill for treatment, equipment, or services by out-of-network parties, we’d like to hear from you. Fill out the form on this page and let us know what your experience was.

Article Type: Investigation
Topic: Consumer
No case events.
Tags: Deceptive Insurance Practices, Health Insurance