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Want out-of-network care? Do your research, experts say

June 11, 2012 12:00:00 AM PDT
When Christine Knopp's son, Brendan, got a deep cut on his face, the emergency room doctor offered the option of a plastic surgeon for the stitches. The surgeon's bill was $2,900. Knopp had assumed her insurance would cover the surgeon, but that wasn't the case.

"He was bleeding from his head, so I wanted to do what was right by him," Knopp said. "We were pretty shocked. We had no idea that that was going to become our responsibility."

The problem was that while the hospital was in the family's insurance network, the plastic surgeon who stitched up her son was not. Consumer Reports says one of the most common causes of medical sticker shock is going out of network.

"A PPO plan might say that it will pay 60 to 80 percent of out-of-network care. That does not mean it will pay 60 to 80 percent of the actual bill, though. It means it will pay 60 to 80 percent of what the insurance company thinks the test or treatment ought to cost," said Nancy Metcalf of Consumer Reports.

Consumer Reports found many examples of patients being hit with astronomical bills, including one woman who was charged $480,000 for back surgery.

"Bottom line, stay in your network," Metcalf said. "If you must go out of network, research ahead of time what your insurance company will pay."

You should also research what the test or procedure should cost. Two services, healthcarebluebook.com and fairhealthconsumer.org, let you search the cost of medical services by zip code. Sometimes you can use this information to negotiate with the non-network provider you want to use.

Finally, if you get a big bill, don't just complain to the insurance company. Enlist your employer and the California Department of Insurance to help resolve the matter.


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