Health Care Charges
The consumer may be personally liable for payment for an inpatient admission, outpatient surgical procedure, or health care service or supply depending on the consumer's health benefit plan coverage.
You may choose to receive care at a hospital based upon the fact it is part of the health plan network. Care in a hospital is delivered by a large number of people. Although some of these persons may be employed by the hospital, physicians are not employed by the hospital. Physicians will bill for their services separately and may not be part of your health plan’s network. Federal law and regulations may prohibit the hospital and physician from inquiring into the insurance plan you may have.
Also, it is very possible there are no physicians of a particular specialty that have a contract with your health plan.
For example, you suffer an injury at home and believe you have a broken arm. You choose to receive care from a local hospital that you know is part of your health plan’s network. When you arrive at the hospital a nurse takes your blood pressure and begins the process of providing care. You are examined by an emergency room physician. This physician is not an employee of the hospital but is in your health plan’s network. You have several X-rays taken of the broken arm. The X-rays are taken by a technician who is under the supervision of a physician specializing in radiology. This physician practices within the hospital but is not a hospital employee. The physician is not part of your health plan’s network. The services this physician provides will be billed out-of-network. The X-ray reveals the injury is very severe and another physician is called into the hospital to provide care. This physician is an orthopedic surgeon. He is also not part of your health plan’s network and will bill for services out-of-network. Your surgeon suggests that surgery is necessary to place screws and rods into your arm to stabilize the broken bones. You agree to surgery. For an operation, you will need not only the services of the surgeon, but you will also receive care from another physician specializing in anesthesia. This physician is also not in your health plan’s network and will bill for services out-of-network.
You receive care and return home to recuperate. You must pay for the care that you received. However, your insurance aids you in that it protects you from some costs of health care. The care you receive from physicians and providers that are part of your health plan’s network will be covered at a higher percentage by your health plan. Also, the physicians and providers have granted you a discount by virtue of being part of a health care network for which they are “in-network”. The physicians and providers that are part of your health plan’s network have also agreed – with your health plan – that they will only seek payment from you for co-payments and deductibles.
The care provided by physicians and providers that are not part of your health plan’s network is covered at a reduced percentage by your health plan. Also, your health plan may calculate your coverage based not on what is charged by the non-network physicians and providers, but rather upon an amount your health plan believes it is reasonable for it to pay. However, because there is no agreement between the non-network physician and your health plan, you may be billed for and be obligated to pay all amounts your health plan does not pay. Physicians are often willing to discuss payment arrangements.
If your plan covers payments at 80% in-network and 50% out-of-network the following may occur based on the facts above:
| Provider | Billed Charge | Network Discount | Coverage % | Health Plan "Allowed" Charge | Patient Responsibility |
|---|---|---|---|---|---|
| In-Network Hospital | $10,000 | $5000 | 80% of Network Discount | N/A | $1000 (20% of $5000) |
| In-Network ER Physician | $1000 | $500 | 80% of Network Discount | N/A | $100 (20% of $500) |
| Out-of-Network Radiology Physician | $2000 | N/A | 50% of "Allowed" Amount | $750 ($375 Covered by Plan) | $1625 ($2000-$375) |
| Out-of-Network Orthopedic Surgeon | $5000 | N/A | 50% of "Allowed" Amount | $1000 ($500 Covered by Plan) | $4500 ($5000-$500) |
| Out-of-Network Anesthesiologist Physician | $5000 | N/A | 50% of "Allowed" Amount | $1000 ($500 Covered by Plan) | $4500 ($5000-$500) |
| Total Amount Owed by Patient | $10,100 | ||||
The consumer should contact their health benefit plan for accurate information regarding the plan structure, benefit coverage, deductibles, copayments, coinsurance, and other plan provisions that may impact the consumer's liability for payment for an inpatient admission, outpatient surgical procedure, or health care service or supply.
The consumer, if uninsured, may be eligible for a discount on facility charges based on a sliding fee scale or a written charity care policy established by each facility.
Prepared by Facility Licensing Group, Dept. of State Health Services