A night of pain sent them to the ER. A surprise bill from the doctor added to the misery
When the hospital is in-network but the doctor isn't, patients can get stuck with the bill.
Steve Zangla held on to his pain for as long as he could, tossing fretfully in bed all night long.
When he couldn't stand the sharp pains in his abdomen any longer, his wife, Colleen, took him to Riddle Hospital in Media. It wasn't far from their southern Delaware County home, the doctors and nurses had always been kind in past visits and — perhaps most important — it was in their insurance network.
So the Zanglas were surprised when, weeks later, they received a $666 doctor's bill that their insurance plan refused to pay.
Along with it came a hard truth about health care: Just because the hospital is in network, doesn't mean all the doctors inside the hospital are, too.
According to the statement, the emergency department doctor who treated Steve for what turned out to be a kidney stone in February was not in his insurer's network and he hadn't met his deductible, so their plan did not cover his portion of the bill.
"So let me get this straight," said Colleen Zangla. "We're in the ER, we're having an issue, we're not thinking about insurance other than we're in the right hospital — and we have to ask for the right provider?"
Surprise billing is the term for what happens to patients who try to follow the rules of their insurance plan, but get tripped up as the Zanglas did. Sometimes it's an ER doctor who isn't covered under the same contract as the hospital where he works. Sometimes it's an anesthesiologist with a different contract than the surgeon and the surgical facility.
It is an evergreen health-care headache gaining new attention as high deductible health plans push more costs to patients and coverage networks become more narrow.
Several states, including Pennsylvania, are considering rules to protect patients from such bills. New Jersey recently approved similar legislation that is awaiting the governor's signature.
Patient advocates say the issue is not as pronounced in the Philadelphia area as in other parts of the country. That's in part because of rules that hospitals and insurers have independently established to hold patients harmless if they inadvertently see an out-of-network doctor.
After hearing from a Philadelphia Inquirer reporter, both hospital and insurance representatives say the Zanglas shouldn't have been billed for an out-of-network provider and plan to reprocess the claim.
But the family's experience – like many consumers, the Zanglas thought it was useless to dispute the bill so they paid it — shows how easy it is for patients to get caught in the middle when insurers and providers don't agree on how much a service should cost.
"It's so difficult for providers and insurers to come to that agreement," said Kevin Lucia, a research professor at Georgetown University's Center on Health Insurance Reforms. "They end up kind of pulling consumers in, so consumers end up being used, in a way, to mitigate the expense."
‘We need to protect consumers’
Contracts between insurers and providers establish rates for various services, and as a condition of the deal, providers agree not to seek additional payment from patients. But doctors without such contracts are allowed to bill patients for the portion the insurance plan did not pay, which is called balance billing.
To encourage their members to use in-network providers, insurers require them to pay a greater share if they go outside the network. But especially in emergencies, consumers can get stuck.
Pennsylvania law protects patients with HMO or PPO plans who see an out-of-network provider during an emergency visit from being balance-billed. The provider and insurer must work out payment on their own.
Now, lawmakers are considering expanding patient protections.
"Especially as we're moving toward high deductibles, more cost sharing, more skin in the game, we need to protect consumers so they're not getting hit with big bills," said Antoinette Kraus, director of Pennsylvania Health Access Network.
Surprise bills often become unpaid bills, spurring providers and insurers to take action, too.
Independence Blue Cross, the region's largest private insurer, includes in its hospital contracts a provision that holds hospitals financially responsible if a member receives a balance bill from a hospital-based doctor they didn't know was out-of-network. Many hospitals simply require contracted doctors to accept the same insurance plans as the hospitals.
Yet patients can still wind up with a bill they weren't expecting.
The doctor who treated Steve Zangla, 59, in February is part of a group that Main Line Health contracts with to provide care at its hospitals, including Riddle.
The health system has similar contracts for radiology, anesthesiology, pediatrics and neonatal intensive care. All are required to be part of the same insurance networks as the Main Line hospitals, though they send bills that are separate from the hospital's, said Bridget Therriault, a spokeswoman for the health system.
So how did the Zanglas get a surprise bill from an out-of-network doctor?
Well, it's complicated.
The Zanglas have insurance from Blue Cross and Blue Shield of Alabama because Steve works for a company with headquarters there.
The Alabama plan offers in-network rates to out-of-state members such as the Zanglas through a partnership with other Blue plans around the country. Here, that's Independence Blue Cross.
That's how the BlueCard program is supposed to work.
But instead of sending Zangla's claim to Independence, the doctor group sent it to Highmark, the Pittsburgh-area Blue Cross plan, and it was billed as an out-of-network service.
Main Line patients are sometimes inadvertently charged out-of-network rates if they are traveling or have an insurance plan based outside the state, Therriault said.
"In all instances, Main Line Health and our contracted physician groups are committed to helping patients resolve unexpected/out-of-network insurance claims," Therriault said in an email.
But it's up to the consumer to figure out that something is wrong, and report it.
Colleen Zangla, 57, said she called her insurance company, and was told she should have sought out an in-network doctor. So she paid it.
But it still seemed wrong, so she emailed the Inquirer's Philly Health Costs project to tell other consumers – and the newspaper — what happened.
"I kind of always thought, 'Oh, they're right, you're wrong,'" Zangla said of her initial reaction.
After the Inquirer contacted Main Line, Zangla said the ER physician group's billing agency called to say they would reprocess the bill, and she may get a partial refund.
In the future, she said, "I'll definitely look at what I'm being billed. It's worth calling and asking questions."
Share your own experience — and what you paid — at Philly Price Check or by emailing firstname.lastname@example.org. Or leave a voicemail message at 215-854-2500 describing the billing issue you would like to share.