At 15, Maili McGraw needed to get rid of the two stubborn baby teeth that were preventing full-sized canine teeth from growing in.
The oral surgeon scheduled the extraction, as well as removal of Maili’s four wisdom teeth at Nazareth Hospital, near the family’s home in Northeast Philadelphia, in early March.
Maili’s mother, Jennifer McGraw, made sure that the surgeon and hospital were part of their insurance network and that the procedure would be covered by their insurance.
It didn’t occur to her to ask about the anesthesiologist. Then came the $2,574 bill.
The family’s employer-sponsored health insurance covered dental anesthesia only in an emergency, according to the explanation of benefits the McGraws received, and the anesthesiologist, NorthStar Anesthesia, was refusing to send a bill to the family’s dental plan.
“I just felt stuck,” said McGraw.
Unexpected medical bills can be jarring and stressful for patients who thought their care would be covered by insurance. Surprise bills often happen when someone goes to an in-network facility but is treated by a provider — such as an anesthesiologist — who isn’t covered. Out-of-network providers aren’t bound by insurance contracts that require them to accept lower, negotiated rates. They can bill patients directly for the full charge.
What makes these bills a true surprise is that they’re often unavoidable, such as when an in-network hospital contracts with out-of-network emergency department doctors. Other times, it simply never occurs to the patient that such a bill could arise.
“You don’t get told who the anesthesiologist is until you’re sitting there in a hospital gown and at that point there’s not much you can do. You could ask them, but what are you going to do if they say no?” said Jack Healy, a research professor emeritus at Georgetown University Health Policy Institute.
The issue is one that has captured the attention of federal lawmakers, who are batting around ideas to address out-of-network bills, though none extend to dental care. A handful of states are considering their own legislation and a few, including New Jersey, have already passed laws that require the provider and insurer to come to an agreement or work with an arbiter without passing on the cost to patients.
That isn’t exactly what happened to the McGraws. After The Inquirer asked about the bill, the McGraws’ health insurer, Independence Blue Cross, reviewed Maili’s case and found the anesthesia bill was incorrectly denied.
But most patients are on their own to figure out whether the bill they’ve received is in error or truly a surprise out-of-network charge. Some may be able to negotiate with the provider for a lower rate or payment plan, but others will end up shelling out cash or getting sent to collections and potentially facing a hit to their credit rating.
“It’s the consumer who gets caught in the crossfire when you’re having those network negotiations,” Healy said.
Dental services can be especially susceptible to surprise bills because insurance coverage is often far less than what patients expect.
Unlike major medical plans, which are required under the Affordable Care Act to cover certain basic benefits, dental plans may have more limited benefits and smaller networks.
Patients often find that procedures aren’t covered — or are only partially covered — and it’s common to run up a bigger bill for services that must be done at a hospital, said James Boyle, an oral and maxillofacial surgeon in York, Pa., and past president of the Pennsylvania Dental Association.
“Calling it dental insurance is somewhat of a misnomer — it suggests everything is covered,” Boyle said.
But the McGraws’ case is even more complicated.
NorthStar Anesthesiology had submitted the charge for Maili’s care to the family’s medical plan. Their health insurer, Independence Blue Cross, rejected the dental anesthesia charge because it “is eligible only if it is a direct result of an accident,” according to the explanation of benefits they sent the McGraws.
That explanation made sense to McGraw — it was a dental procedure, after all. Surely the problem was that the bill should have been submitted to their dental plan, she thought.
She called the family’s federal BlueCross BlueShield dental plan, which confirmed it covered anesthesia.
But when she called NorthStar, the provider refused to submit the charge to the family’s dental plan. As McGraw spent months trying to work out the problem, NorthStar’s letters got more aggressive, threatening that the bill would be sent to a collection agency. McGraw asked NorthStar to put her account on hold as she challenged the charge, but the company refused, she said.
“They behaved more like a collections agency than a health-care provider,” McGraw said. “I’ve never had this type of situation where the provider isn’t willing to work with you and put the account on hold while something is being appealed.”
When providers have a contract with an insurance company, they’re required to submit charges for patients’ care. But when there isn’t a contract, providers aren’t obligated to bill insurance — they can bill patients directly, Healy said.
“In these scenarios where a service is not covered by insurance it is our billing practice to bill the patient so they can connect with their insurance carrier and help to get this resolved,” Ashwini Kotwal, chief financial officer of NorthStar, which is based in Texas, said in an email. “We try hard for patients to get in-network benefits and for all claims to be processed by payers in a timely manner,” but in the meantime, patients are liable for the bill.
McGraw tried to resolve the issue with her dental plan, only to eventually learn in July that her medical plan had made the mistake. It was their medical insurance that had paid for Maili’s procedure and the anesthesia should have been covered, too.
Nazareth Hospital billed $12,261, which the medical plan reduced to $1,168 and paid, with McGraw owing only a $50 co-pay. The medical plan also paid the surgeon $784, reduced from a bill for $2,404.
But the plan did not initially process the anesthesia as part of that procedure, and rejected the charge. It has since been reprocessed and paid by Independence, since NorthStar is part of the insurer’s network.
“Now that we are aware of the issue, the McGraws should not receive any future bills for this service from this provider,” Donna Farrell, vice president of corporate communications for Independence Blue Cross, said in a statement.
“We encourage members to call us if they have any questions about their health care services, especially in complex situations that may necessitate coordination of services across different benefits,” she said.
McGraw said she is pleased to have the bill resolved, but the ordeal has made her concerned about a bigger problem in the health care system and she worries how other families who can’t spend hours fighting medical bills will fare.
“It’s maybe a bigger question about health care billing in general, not just this situation. It’s a complex system and it’s not entirely clear why something was covered, or not covered, or covered only at this rate. You don’t really know who you can ask about it,” McGraw said.