A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

As a lifelong resident of southeast Louisiana and a veteran of numerous weather and flood-related events that have required me to use my homeowners and flood insurance, I am very familiar with gaps in insurance coverage.  Insurance policies are very detailed agreements that many of us read over quickly, but really don’t know what is or is not covered until the time comes to make a claim.  And although we do tend to know the cost of our insurance premium, only after an event do we realize the true cost of the insurance selected and the various gaps that may exist.  These same types of surprise insurance coverage gaps are now appearing in healthcare.

It is no longer the norm to see a health insurance policy that simply spells out a deductible and the percentage of medical bills that you as the consumer will pay across the board.  The goal of purchasing health insurance is to allow you and your family the security of knowing that if you are carrying out preventive health care or have an emergent medical need for health care, you will be covered and your costs will be manageable.  That has become a challenge.

Unfortunately, health insurance plans have become increasingly more complicated, for patients and physicians.  Even discerning consumers can find themselves facing gaps in their insurance.  Many insurance companies have several products, each with potentially multiple tiers, making purchasing and using health insurance more confusing and difficult for consumers.  Premiums for narrow insurance networks tend to be lower on the front end, making them more appealing, but they may lead to unexpected gaps in coverage. With the increase of insurance companies narrowing and tiering their insurance networks, patients may be treated by physicians who are outside of their health insurance network without their knowledge.  Patients are then expected to pay the difference between the actual charge for the out-of-network physician’s care and the amount the insurance company decides it is going to pay after copay and deductibles.  This is known as balance billing and may be seen by patients as “surprise medical bills” when in reality it represents “surprise coverage gaps.”  To make matters worse, insurance companies have sought in various jurisdictions to have lawmakers ban physicians from appropriately billing for the medical care they provide to their patients.  This does not address the true problem.

This issue is particularly concerning for hospital-based physicians such as physician anesthesiologists, radiologists, pathologists, hospitalists, emergency medicine physicians, and neonatologists.  These physicians very often care for patients at an in-network facility.  It is not that these physicians don’t want to be included in the network, but rather the payment rates are not calculated fairly.  As a physician, it is not as simple as sitting at a table with an insurance company and negotiating payment for the medical services we provide to our patients.  In fact, I have never directly negotiated a payment rate in my career.  I am told what I will be paid, and I can choose to accept it, or not be included in the network.  Thus, many health care providers find themselves out-of-network and seeking appropriate payment from patients for their services after the insurance company has paid their portion.

Obviously, this problem is extremely complicated, but there are a few strategies that patients can use to help avoid these unexpected medical bills:

1. Before having a medical procedure, ask who will be involved in your care — from physician anesthesiologist to pathologist – then try to find out from the insurance company whether they are in your specific plan’s network.

2. Call your insurance company to verify that not only the hospital, but also your particular physicians and other providers are in-network.

3. Low premiums don’t necessarily mean affordable care. Always ask for details about what the health insurance plan covers and does not cover before signing up to protect against high co-pays, deductibles and a plan with a narrow network of physicians.

4. If an unexpected medical bill does occur, raise significant concerns with your insurance company. If you do not receive an adequate response, reach out to your state-level department of insurance for assistance.

Insurance plans with narrow networks remove or reduce patient choice by providing coverage with a limited number of physicians, high deductibles, co-pays, and coinsurance.  These inadequate networks limit insurance companies’ cost and shift them to patients and other stakeholders. I recommend patients spend time analyzing their current health insurance and become more familiar with the potential sites and locations where they may receive health care services and the physicians they may encounter.  After a thorough analysis, you, the patient and the consumer of the insurance company, may find that the low-cost health insurance that seems very appealing, may be riddled with surprise gaps in coverage, costing more in the long run.

Kraig S. de Lanzac is an anesthesiologist.

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