Stealthy Health Plan Changes Could Cost You More

By Richard Asa @Rick Asa
December 14, 2015

Preferred provided plans aren’t what they used to be, especially if you go out-of-network.

With open enrollment for health insurance plans ongoing, it’s buyer beware for out-of-network costs. 

For a long time, some of you’ve been used to the flexibility of a preferred provider organization (PPO) that gave you the choice of seeing in-network or out-of-network healthcare. Even with higher out-of-network costs per visit, you could still expect the total cost to be capped for the entire year. 

You’d better start reading the fine print. To balance healthcare costs more and more health insurance plans have no cap on out-of-pocket costs if you see doctors or and receive medical care outside of your network. It could slip by anyone.


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An actuary, Vince Hess of Grandview, Mo., found himself with about $800 in costs after surgery for a broken hand in 2013. Hess did his homework, and confirmed that his surgeon was in network, he told National Public Radio (NPR). 

The operation was done at an in-network surgical center, but the two anesthesiologists involved weren’t part of that network. 

"Everything added up pretty fast," said Hess, 57, who felt he had been left in the dark. "I ... have read a thousand health insurance contracts. That's the irony, that I got burned. I don't know how the average person does it who is not as familiar."

Forty-five percent of “silver” PPOs plans on the market for use for the first-time next year have no annual cap on out-of-network costs, according to an analysis by the Robert Wood Johnson Foundation. 

In 2015, 14 percent of silver plans had no cap. In 2016, 30 percent of the total silver plans offered had no annual out-of-network cap. 

One patient, for example, was told his Blue Cross Blue Shield gold-level plan would no longer be offered in 2016, presumably because the insurer lost money on it. That was the case for many health insurers in 2015 that offered plans through the Affordable Care Act marketplace.

The plan he was referred to, and would be enrolled in automatically unless he chose another, had “unlimited” out-of-pocket expenses for out-of-network providers. 

In 2015, he had received separate billing from a gastroenterologist and a pathologist who were not part of the hospital that did a colonoscopy. That was a big surprise after he paid the full cost of the procedure up front. 

You’re thinking you’ll just make sure you are treated at in-network facilities by in-network doctors, but it isn’t that easy. 

Many networks, even PPOs, have become narrower to save insurers money and target specific doctors’ services. Insurers note that can lead you to highly qualified doctors that are cherry picked for their networks. 

But you could find yourself, or your child, in the hands of out-of-network doctors with privileges at particular hospitals, as was the case for 9-week-old Sienna D’Andrea. The baby needed heart surgery. 

Her frantic parents, alarmed by the diagnosis and willing to follow their in-network doctor’s orders, quickly got their daughter to the hospital. 

The surgery was a success, but soon large bills started filling their mailbox, the D’andreas told The New York Times. Sienna, it turned out, had part of the surgery done at an in-network hospital by out-of-network doctors who were recommended. 

“When the doctors work in the hospital, not for the hospital, which is often the case, they’re not obliged to join the same networks as the hospital,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. 

“And patients generally have no say in selecting those doctors. Sometimes the patients don’t even see them — for instance, if their x-rays get sent to a radiologist or their tissue to a pathologist, patients won’t even know the name of that doctor until the bill comes.”

With those referrals to specialists happening routinely and without your knowledge, the only thing you can do is make sure that every procedure you have done, and every x-ray or MRI read by a radiologist, is by healthcare providers employed by the in-network hospital. Again, easier said than done. 

There is one thing you can do, as the patient who had the colonoscopy realized. Make sure that your out-of-network bills are sent to your insurer because a portion of those is often covered. Don’t assume the hospital in which your procedure is done will do that, because it’s likely that it won’t.

You can also get used to it, so you expect it when you shop for health insurance. It’s a new normal out there, and you must be your own advocate and healthcare sleuth. Given the number of separate bills the D’Andreas had to slog through, even Sherlock Holmes might not be of much help. 

Not having any maximum cap on those costs "is what you (traditionally) expect ... in a plan that doesn't offer out-of-network benefits," Robert Wood Johnson Foundation researcher Katherine Hempstead told NPR. "You're paying a deductible and then some kind of co-insurance ad infinitum. The average PPO for sale in 2016 is less comprehensive than what was called a PPO in 2015."

Caveat Emptor. 


April 06, 2020

Reviewed By:  

Christopher Nystuen, MD, MBA