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Forced provider care nightmares

What you don’t know can hurt you

Imagine heading into surgery knowing that your doctor and hospital are in-network, but weeks later receiving a bill for an out-of-network anesthesiologist. You assume it’s an error. After all, who gets to pick an anesthesiologist?

An anesthesiologist is considered a forced provider, and the practice of balance billing involves charging consumers the difference between what the health insurance company covers and what the provider charges. Such circumstances leave consumers frustrated and helpless—and their budgets strained by the unexpected expense.

The practice of balance billing demonstrates why understanding a major medical health insurance plan before purchasing it is critical. But understanding a plan means knowing which questions to ask. Here are three questions you may not think to ask.

1. How does the carrier treat forced-provider care?
While many carriers are adding forced-provider provisions, others still impose penalties. Will you be penalized for seeing a non-network provider, such as an anesthesiologist, radiologist or ER physician, despite your inability to choose?

You may think these providers are covered if you see them at an in-network hospital, but that is not always the case. Many hospital-based physicians opt out of provider networks and bill independently — at their own rate. Others may be employed by physician groups and are not given the option to join specific providers.

2. What are the health insurance plan’s preexisting condition restrictions and other exclusions?
Such restrictions may impact large claims as well as smaller “everyday” expenses. In some cases, certain medications may not be covered during the preexisting condition limitation period. In addition to preexisting conditions, pregnancy and certain professions may also be excluded.

What happens if you have a large claim that seems to be unrelated to the pre-existing condition, but the carrier thinks otherwise? For instance, what if your diabetes is considered a preexisting condition and you have a stroke during the preexisting period? Will the diabetes be considered a complicating factor that negates the claim?

3. How are wellness claims treated?
Many health insurance carriers in the individual market impose a waiting period as long as one year before they will cover wellness claims. This may alter your regular wellness schedule. In addition, you should ask how wellness expenses are covered after the annual first-dollar coverage limit has been reached. Some plans allow excess claims to go toward the deductible and co-insurance.

As with anything, being an informed consumer will help you avoid stressful and costly misunderstandings. Be sure your agent or broker thoroughly explains your plan. For additional guidance, check out the article “Your guide to choosing health insurance coverage” and its sidebar “Things to consider as you shop around.”