Connor is a 68-year-old Westchester resident with heart problems, insured in a preferred provider organization (PPO). He had a stent put in last year, and when he was experiencing extreme shortness of breath he rushed to his local in-network hospital. The heart problem was too severe to be treated there, so he was transferred to a major academic medical center nearby, also in-network. After observation and testing, his treatment team decided that he needed emergency open heart surgery to implant a special pump. Though he was at an in-network hospital, neither the surgeon nor his assistant was in-network. The surgeon billed $71,000, out of which Connor’s insurer’s out-of-network benefit paid $29,000. The assistant billed $35,000, out of which Connor’s insurer paid $6,737. In total, Connor was left owing more than $70,000 for his surgery, even though he had “good insurance” and went to in-network facilities for his emergency treatment.

Connor is one of many New Yorkers who have been blindsided by balance billing, when patients are charged the difference of what an insurer agrees to pay a provider.

The problem of “surprise” out-of network medical billing has recently gained attention in the press, including an article in today’s New York Times. Earlier this year, the New York State Department of Financial Services released a report, An Unwelcome Surprise: How New Yorkers Are Getting Stuck with Unexpected Medical Bills from Out-of-Network Providers. 

This year, Health Care For All New York made a statement on out-of network billing, including recommendations: New York should protect insured consumers from “Surprise” out-of-network billing, require all insurers to have adequate networks and offer a reasonable mechanism to go out-of-network when medically appropriate, and ensure transparency about billing from health providers and plans.

Visit Community Health Advocates  for the Out-of-Network DIY Appeals Packet if you think your plan is not reimbursing you enough for out-of-network care.