ROBERT SIEGEL, HOST:
In network and out of network - for people with health insurance, those words mean money. If you don't want to get charged extra, stay in network. It sounds straightforward, but as Carrie Feibel at Houston Public Media explains, hidden traps can leave patients with large bills.
CARRIE FEIBEL, BYLINE: Jeffrey Hopper is a Little League coach in Austin, Texas, so he knows all about following the rules. Still, accidents happen. During a practice session last June, an errant baseball smashed into his face. His wife, Jennifer Hopper, rushed to the field.
JENNIFER HOPPER: His eye was swollen shut enough that we weren't sure if he could see.
FEIBEL: Jennifer Hopper knows there are rules when it comes to insurance, so she made sure to drive him to an in-network hospital in Austin. In the end, Jeffrey was OK. He broke some bones around his eye, but they healed and his vision was fine. Jennifer, however, was surprised by what happened next. She had already settled the copayments for the ER, but then the emergency room doctor sent a separate bill for more than $700.
HOPPER: It felt kind of random. Like, how do I know who's going to charge me and who's not going to? So that was the first question.
FEIBEL: Like many patients, Hopper assumed that if she went to an in-network hospital, the doctors who worked there would of course be in-network. Turns out, that's not necessarily true. Emergency room doctors, radiologists and anesthesiologists often don't work for the hospital. They work for themselves, and it's up to them to sign their own deals with insurance companies. As Hopper found, many of them don't.
HOPPER: I couldn't let that go. It just felt wrong because there was no way out. There was obviously no way we could have avoided the situation given our emergency.
FEIBEL: The problem has become so common that a think tank, the Center for Public Policy Priorities, looked at the three biggest insurers in Texas - Humana, Blue Cross and United. They found that in over half of Humana's Texas hospitals, none of the ER doctors were actually in Humana's network. For United, this occurred at just under half of the hospitals and for Blue Cross, at about a fifth. Stacey Pogue wrote the report. She says it's unfair to patients.
STACEY POGUE: No other consumer services are sold to us this way. It would be like going into a restaurant and ordering a meal and then getting a bill from the waiter and from the restaurant separately and the cook separately and the busboy separately. And some of them will negotiate with you on the price, and some of them accept coupons, and the others don't.
FEIBEL: The Texas insurance industry says it would like ER doctors to join their networks, but they can't force them to. The ER doctors say insurance companies often don't pay them enough, even if they do join the network. Doctor Bruce Moskow is president of the Texas College of Emergency Physicians. He says the economics of ERs are complex.
BRUCE MOSKOW: In an emergency department, we see everyone, and we're not even legally allowed to ask if they're going to pay their bill. And large numbers of people pay nothing.
FEIBEL: There is a mediation process for some of these out-of-network bills, but it's only for certain types of insurance and certain situations. Jennifer Hopper says she spent weeks appealing her bill and finally filed a complaint with state regulators. After that, the bill simply disappeared. But she tried to get ready for the next ER visit, searching her plan to find ER doctors who are in-network, but she found fewer than five in all of Austin.
HOPPER: So the reality is all the transparency in the world doesn't change the fact that knowing everything, I could not be sure that I would get a different outcome.
FEIBEL: Some states have tried to tackle the problem. In California, ER doctors can't send a separate bill to HMO patients. In New York, a new law requires out-of-network doctors and insurers to hash out payment on their own and leave patients out of it. Texas legislators have held hearings on this issue recently, but so far it hasn't led to any new regulations. For NPR News, I'm Carrie Feibel in Houston.
SIEGEL: And that story is part of a reporting partnership of NPR, Houston Public Media and Kaiser Health News.
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