Patients in for a surprise after visiting an in-network hospital

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    NASHVILLE (WSMV) — Whitney Pastorek got her annual mammogram from a hospital in her insurance network, not thinking twice about it, as she’d never paid for the preventative checkup before.

Until the bill game; $403.02 from a doctor she didn’t know.

“I was shocked. I didn’t know who that person was,” Pastorek said.

Doug Showalter thought he was being financially savvy when he chose a hospital within his insurance network when he thought he got was a spider bite.

Then came the whopping bill.

“It was just a little bit under $1,000 dollars,” he said.

Pastorek and Showalter were in for a shock when they started asking about the bills.

Although both has chosen hospitals within their networks, they got billed from doctors out of the insurance network.

Pastorek remembers how the billing specialist at St. Thomas hospital, where he got her mammogram, explained the bill to her.

“Even though St. Thomas is in network for you, that radiologist is out of network. And I said, why didn’t the facility warn me?” Pastorek asked.

News4 Investigates found while hospitals or clinics may be in your insurance network, that doesn’t mean all their doctors or specialists are in network, or are actually employees of the medical center.

Pastorek’s insurance statement clearly reads that an out-of-network radiologist read her scans.

Showalter too had the same experience, as a St. Thomas hospital was also in his insurance network.

But a doctor who assisted in his care was out-of-network.

“It makes me feel incredibly taken advantage of,” Showalter said.

Despite our repeated requests for an interview, a St. Thomas spokeswoman declined, writing in part, “Though we strive to stay aligned on in-network status, there will occasionally be instances where a physician or contractor is out-of-network.”

According to the Kaiser Family Foundation, which studies national health issues, on average, 1 out of 6 planned procedures result in an out-of-network bill.

“This is the number one affordability concern among privately insured people,” said Karen Pollitz, senior fellow with the Kaiser Family Foundation.

Pollitz said they are repeatedly seeing doctors working for practices owned by investors and do not take insurance.

So what are patients supposed to do to avoid these bills?

Before a procedure, make sure to start asking financial questions before hand, inquiring if all the people who will be involved with your treatment are within your insurance network.

Pollitz said to especially ask about radiologists, anesthesiologists, pathologists and intensive care doctor, as those professions are often out of network.

Pollitz recommends if you need them and they’re out of your insurance network, ask if a specialist can be used in your insurance network.

So what if you have one of these surprise bills now?

Pollitz recommends calling the hospital and trying to negotiate, asking if you can just pay the amount that would be charged if the doctor or specialist had been in network.

Unless you are diligent, patients are finding that you will face pressure to pay.

“I tried to fight it for a good four months, and eventually I couldn’t. No one was willing to help me at all. I just ended up paying it,” Showalter said.

But Pastorek did not pay, and repeatedly appealed, and eventually won, dodging the $403 bill.

“Most Americans don’t have $400 to pay for an emergency,” Pastorek said.

News4 Investigates also checked with Vanderbilt Medical Center and HCA, two of the other largest hospitals in Middle Tennessee, asking if they have doctors who do not take the insurance that the hospital accepts.

A spokesman for Vanderbilt wrote back,

“The “surprise billing” doesn’t necessarily apply to VUMC. Our physicians are, for the most part, all employees of VUMC (the physician practice group is called Vanderbilt Medical Group) and is the largest practice group in Tennessee, currently employing ~1,950 physicians. Because they work for VUMC, billing for physician services is part of VUMC and in line with the insurance plans we accept. I don’t know about Nashville’s other big hospitals but surprise billing hasn’t been one of those major issues we’ve had to address.”

A spokeswoman from HCA replied,

“We are sensitive to bills that patients may receive from independent physicians, and we encourage all physicians to participate in the same insurance networks as we do. Our hospital-based physician contracts prohibit balance billing.”

News4 Investigates asked HCA if their response meant that doctors are only encouraged, not required to take the same insurance as the hospital, but did not get a response.

In 2022, new federal legislation aims to tackle these surprise bills to a higher degree. You can read all about the new law that will come into affect here:

Until then, Pollitz said it’s best to be your own advocate and not be afraid to ask about billing before your procedure.

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