How to Avoid Out-of-Network Charges

Sorry, you can’t.

One of the many reforms brought about by the Affordable Care Act was a cap on out-of-pocket charges to healthcare customers. This provision was meant to do something about the fact that medical bills were implicated in more than half of all personal bankruptcies in the United States (according to one Harvard study), and that even families with good health insurance could be plunged into poverty by a hospital visit.

Yet for some reason, the law contains a loophole: out-of-network charges are exempt from the limit. According to Maura Collinsgru, healthcare program director of the New Jersey Citizen Action advocacy group, it’s all too easy to fall into this loophole and rack up surprise medical bills.

Collinsgru says that even if you make sure you are using a healthcare provider that is in your insurance network, an operation by a visiting specialist, such as a neurosurgeon (that you never authorize) could still bankrupt you. “You can do all your homework and get all the pre-authorizations for everything and do everything you’re supposed to do, and you still could be subject to a surprise out-of-network bill,” she says.

Once Collinsgru went to a hospital and was presented with standardized paperwork authorizing care. The staff told her everything would be in-network, so Collinsgru annotated the forms to say that she was authorizing care only by pro-viders in her network. The hospital wouldn't accept it. Now Collinsgru is part of an effort to change the law on a statewide scale.

To remedy the situation, NJ Citizen Action is pushing for a bill that would ban surprise out-of-network charges.

Collinsgru will join a panel of legislators and industry leaders at an NJ Spotlight event on Friday, January 27, from 8:30 to 11 a.m. at the Trenton War Memorial. Neil Eicher of the NJ Hospital Association, Larry Lewis Jr. of Aetna, Linda Schwimmer of the New Jersey Health Care Quality Institute, and state Senator Joseph Vitale will also be there. Tickets are free.

NJ Citizens Action has been trying for years to do something about the problem. Collinsgru believes the effort to fix surprise bills is gaining momentum. The proposed legislation is one of few laws that has the support of both the New Jersey Business and Industry Association and labor unions.

“I think that coalition of unions and the NJBIA being able to take the same side is really helping to build momentum in the legislature. It is a strange set of bedfellows,” she says. One reason for the existence of this unusual set of allies is that out-of-network charges are a major reason for increasing health-care costs, accounting for about $1 billion in healthcare premium costs in New Jersey.

To Collinsgru, the existence of surprise medical bills is a symptom of the fragmented, patchwork nature of the healthcare system. “There’s a lot ofplayers and a lot of moving parts within the same institution, and not a lot of commonality and unity among some of those parts,” she says. “Consumers have no control over it. And where consumers have no control, they should be protected.”

For example, if you go to an in-network hospital, the anesthesiologist there might not be covered. The hospital could order lab tests from a lab that is not covered. One of the doctors on call might be out of network, and the patient would never have any say in any of it. Surprise out-of-network charges are already banned in emergencies, but Collinsgru wants to extend that ban to any kind of care.

Collinsgru says she has heard from patients who have unknowingly incurred bills of tens of thousands of dollars or more.

Collinsgru grew up in Cinnaminson, where her father was a postal worker and union representative and her mother was a consultant who did retirement planning, and also served as the mayor of the small town. Collinsgru worked as a special education advocate for several years but switched to healthcare advocacy in 2013 after taking a course about the Affordable Care Act.

“I decided I would put my skills into action as a health policy person,” she says. “When I started, it was like joining the Super Bowl.” The ACA was just beginning to be implemented. Four years later, the Republican-led government has set the wheels in motion to “repeal and replace” the ACA, and NJ Citizens Advocacy is gearing up for another big battle.

“The ACA is doing a lot of good. Having lived in the real world myself, I know family members, friends, relatives, and community members who all had to live without insurance for a time because of the healthcare crisis that preceded the ACA,” she says. “That’s what led me to pursue this.”

— Diccon Hyatt