Special Report: Not in the Network

PORTSMOUTH, Va. (WAVY) – The practice known as balance billing is legal in Virginia, but it can lead to a costly surprise when patients find out who's really in their health plan network and who's not.

The typical example involves someone who goes to an in-network hospital, and assumes any treatment they get at that hospital is also in-network.

That’s what happened to Anna Bruffy of Virginia Beach. She went into a local hospital last year for treatment for her epilepsy, but she was also referred to a mental health provider while she was there. Same hospital, same building, but different department.

“I waited several hours,” Bruffy recalls. “And when the doctor did come in I saw him for a whole ten minutes.”

The brief encounter proved costly several months later. After nearly a year, she received a surprise bill for about $2,000.

Fortunately, Bruffy had seen our August investigation The Confusing Cost of Care about hospital billing. It included the Hampton-based Patient Advocate Foundation, a non-profit that helps people with hospital billing problems.

“I was watching your broadcast and I had decided to call you,” Bruffy said. “The Patient Advocate Foundation really helped me.”

The head of the PAF, Alan Balch, Ph.D., says he sees hundreds of balance billing cases in a given year. “You may have whole departments that are not part of the contract within an in-network facility where (a specific medical group) is not part of the contract with the insurance plan.”

Sometimes balance billing can also result from outdated information on a health plan website.

Thomas Ema of Williamsburg has an immune deficiency disorder which requires getting an infusion of gamma globulin every thirty days. Each one costs about nine thousand dollars. His wife Liz had checked with their health plan.

“It would show the doctor and hospital being in-network, and it did that every time I logged in,” said Ema.

But the website information was out of date. In fact, the provider was no longer in their network.

“We started getting huge bills from a medical provider that we thought we had in our network,” Thomas said. They soon totaled more than $60,000.

Read: Balance Billing by Health Care Providers

Ema made a decision none of us ever wants to make involving money and medicine. With the bills piling up he decided he couldn’t afford his vital treatments.

“It broke my heart because of him stopping treatment,” Liz said. “He said I can't afford to pay that out of pocket.”

And without the treatments, Tom developed lymphoma. He changed providers and is now getting the treatments he needs from an in-network provider at the in-network rate.

With the help of PAF, and screen shots that Liz had saved, the Emas were able to get nearly all of the surprise bill reversed.

A recent study found that about one in seven emergency room visits and one in 11 hospital stays resulted in the patient getting a surprise balance-bill.

“We see hundreds of them a year,” Balch told 10 On Your Side.

Surprise billing is not regulated in Virginia, however six other states do have strong consumer protection - meaning patients don't have to pay extra provider charges when they get treatment in an in-network facility.

A study this year by the Commonwealth Fund found that Maryland has comprehensive protection against balance billing, West Virginia and North Carolina have some protection, but DC and Virginia have essentially no protection.

That’s why you need to examine your network’s list of providers closely, and make sure that the information is up to date.

Balch says his organization supports a federal law that would standardize the rules and restrictions surrounding balance billing for every state, but for the time being the issue is taking a back seat to the larger debate on health care reform in general.

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