Surprise Medical Cost: Just because your hospital is ‘in network’ doesn’t mean your doctor is

Local News
Medical claim photo_1558132204949.png.jpg
  • A parent compared the bills from two similar urgent care visits and saw unexpected cost differences.
  •  We learned that cost can depend on the doctor you see even when the clinic you visit is “in network”.
  • President Trump is taking on similar issues at the national level.

SPRINGFIELD, Mo.– When you’re looking for medical attention, typically your first step is finding out which hospital your insurance provider considers “in-network”. A family in Springfield just learned the hard way that you’ve got to go one step further if you want to make sure you don’t get a surprise charge.

Back in late April, a father of two informed the KOLR10 news team that he’d run into a unique medical hassle.

“So, you are saying, I have to check which doctor is on duty at Urgent Care before going for service…”

According to the man, who we chose not to identify, he took his son to Cox Health’s Pediatric Urgent Care on April 2nd, 2019. His son, 6, was running a fever. Normally, he says, they’d wait that kind of thing out but this one lasted a little longer than expected. As a precaution, he took him to Urgent Care.

The visit went as expected: They saw the doctor, got antibiotics, and his son recovered. And, the bill was what they expected: Insurance covered most of it and the family paid $35 out-of-pocket.

Yet something wasn’t right.

You see, about two months before his son’s trip to Pediatric Urgent Care, the dad took his daughter to the same medical facility for the same thing, but when the bill came it was $108.38 out-of-pocket..

He gave Ozarks First a chance to study the bills from each visit, and we attached the redacted copies in the gallery below.

Taking a look at the bills for each visit you’ll notice a couple of similarities.

  • Each bill is for a single “Medical Examination”. There are no additional charges.
  • The “Amount Billed” for each visit is $108.38.

However, you’ll also notice some key differences.

  • The “Allowable Amount” on the bill for his son’s visit (the amount his insurance company was willing to cover) is $73.38. You’ll notice the insurance company made good on that payment in the “Amount Paid” line.
  • The “Allowable Amount” for his daughter’s visit is blank. The “Amount Paid” by the insurance company according to that same bill is $.00.
  • The final difference is the provider listed on each bill. For his son, Tajouri, Mehdi, DO is listed. For his daughter, Lyon, Jess, DO is listed as the provider.

So, what’s the deal?

Is how much you pay really based on each individual Urgent Care provider?

That’s what the father wanted to know when he contacted customer service with United Healthcare, his insurance provider. You can see their entire conversation in the photo attached.

“So, you are saying, I have to check which doctor is on duty at Urgent Care before going for service,” the dad wrote. “And when I take my children to Cox Pediatric Urgent Care I need to find out which network the Doctor on duty is a member?”

“Technically yes,” the insurance rep wrote back. “or you can ask how they bill their service. Claims can be billed either under the group or individual physician.”

“So just because they work at the hospital, it does not mean they are IN network?”


For the father, this seemed impossible. Never in his life had he been given the choice of who to see when visiting an urgent care facility or emergency room. Typically, they call your name, you get a room, and a random doctor takes care of you.

How are you supposed to know if your insurance will or won’t cover a visit from the next doctor your “in network” hospital sends your way?

That’s exactly what we asked Trevor Croley, an insurance broker based in Springfield.

“It happens, unfortunately,” Croley said. “And part of that is maybe when a hospital or a facility has a vacancy suddenly and they have to bring in a temp doctor or a traveling doctor.”

Luckily for people in the Ozarks, Croley says this is not a common problem in the Southwest Missouri area.

“We have hospital systems that generally coordinate benefits with insurance carriers,” he said. “I would think you would see that with a more rural hospital setting where staff may be so tight that when they lose one doctor they’ve got to bring in a temp doctor.”

What do you do if you find yourself in that situation? Here’s what he suggests:

1. Study your insurance plan and the specific benefits you pay for:

Croley says often people will sign up for medical insurance and assume that means they can go to any hospital or see any doctor they want. That is not the case. Instead, he says you should know which hospital network your insurance suggests and know which of the doctors in that network may work as an independent contractor through the hospital.

See tip three for what to do in an emergency room or urgent care scenario.

2. Ask an abundance of questions when medical professionals suggest treatment:

Medical procedures don’t work on a set rate. Like many services, you can ask for quotes on certain treatments and (when you aren’t in immediate need of medical attention) shop around. Croley says you should also keep in mind that a visit to the doctor for one treatment could open the door to another medical issue. If an extra test or lab visit is suggested, make sure to ask if it’s covered by your insurance before agreeing to have it done.

3. Finally, and maybe most importantly…YOU CAN DISPUTE UNUSUAL CHARGES:

If you see something on a bill that doesn’t make sense, contact your insurance provider and contact the hospital you visited.

In the case of an emergency room or urgent care visit, this tip is crucial. You may not have time to split hairs about who is providing you with a lifesaving medical treatment. In that case, your best hope might be following up with the hospital.

In the case of the father who contacted our news team, this ended up being his course of action.

During our investigation, the hospital was alerted to his issue and was able to confirm that both doctors he saw should’ve been considered “in network”. Cox Hospital later confirmed none of their urgent care doctors work as independent contractors.

The hospital determined the problem started with his insurance company, who the hospital says failed to enroll one of its doctors “in network”.

The insurance company responded to our investigation with the following statement: 

“We have reprocessed the claim for the care provided to our member’s daughter in February and will work with CoxHealth to ensure he receives a refund. We apologize for the inconvenience and appreciate his patience as we worked to make this right.” 

In a similar case out of Austin, TX, a schoolteacher named Drew Calver was billed nearly $110,000 dollars (after insurance) for the emergency treatment he received during a heart attack he suffered.

Calver would later meet with President Donald Trump, who recently took up the mantle against these “surprise medical bills”.

“It’s ruined people’s lives,” Trump has said. “They leave a hospital with something they think is going to be routine and they end up in court. They end up going to court and they end up with lawyers’ bills.”

Now, the president is urging lawmakers to address “surprise medical bills” and make changes to how emergency room visits are charged.

“In an emergency care scenario where the patient has no meaningful opportunity to choose the medical facility and providers, patient cost-sharing should be limited to in-network amounts,” Assistant to the President for Domestic Policy, Joe Grogan wrote in a recent CNN Op-Ed.

“In nearly every other consumer market, people expect to be told a price of a good or service upfront so they can make an informed decision about agreeing to pay, negotiating or seeking the good or service elsewhere.”

For now, while lawmakers consider how to reform this issue, you can plan ahead. Mercy hospital told reporters all of their doctors should be “in network” if Mercy hospital is in your insurance network. Of course, to be safe, Mercy welcomes any calls you may have about specific providers.

Cox Health delivered the following statement during our investigation:

“As a general rule, if CoxHealth is an in-network provider for health care under a patient’s insurance plan, the providers they see at CoxHealth will also be considered in-network. For example, if CoxHealth is in-network for a patient who comes to one of our urgent care locations or emergency rooms, all providers the patient interacts with in that location would be considered in-network.

However, what is ultimately considered in-network for a particular patient is decided by his or her insurance company, not CoxHealth. If patients have any questions about whether a provider is covered under their plan, we advise them to contact their insurance company to confirm that information.”

Copyright 2020 Nexstar Broadcasting, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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