A patient can make sure their healthcare facility is in-network, but still bear a hefty bill if their providers and insurer are out of sync, said Sheldon Jacobson in a column for the Chicago Tribune.
Mr. Jacobson, who had a family member become very ill in 2021, described jumping through hoops to make sure the providers, surgeon and facility his family chose were in-network with their insurer. However, as the facility tapped out-of-network specialists, Mr. Jacobson's family was forced to bear the additional costs.
While states like Illinois have patient protections against these moves, payers may have stipulations that make it more difficult to cover an out-of-network specialist at an in-network rate. One clause is a requirement that to be covered, services like pathology be conducted on the same day as in-network procedures.
Mr. Jacobson described these circumstances as payers and providers being out of sync, and usually results in a provider billing a patient directly over these largely unspoken rules.
As for a solution, Mr. Jacobson said the system requires "a seamless network of providers" accessible to members of all insurance companies — an idea that could take the form of a single-payer system or a uniform set of rules that applies to all payers equally.