The Risks of Network Medical Plans and Unqualified Hospitals

Published on October 6, 2023, by Law Office of Matthew L. Sharp

Insurance Bad Faith

The Risks of Network Medical Plans and Unqualified Hospitals
You did the right thing. You maintained health insurance coverage through your employer or purchased your own plan through the marketplace, but in your time of need, you ended up at a hospital that couldn’t care for your condition. This is, unfortunately, one of the risks of network medical plans and unqualified hospitals.

But at the Law Office of Matthew L. Sharp, we know that patients have more rights than they think they do. We invite you to schedule a no-cost, no-obligation case evaluation with an experienced Reno health insurance dispute attorney to learn more about your options.

In-Network vs. Out-of-Network: What It Means and How It Impacts Your Care

Health insurance plans provide coverage pursuant to policies for in-network care. Insurers are not required to cover any costs related to out-of-network care, although there are some notable exceptions. For example, emergency services are typically covered regardless of where you receive care.

Let’s break down the differences between these two terms:

  • In-network – A health care provider or facility that maintains a contract with your health insurance company to provide services at a pre-negotiated rate.
  • Out-of-network – A health care provider or facility that has no contract or agreement with your health insurance company.

Seeing an in-network doctor does not mean that you will not receive a medical bill. Instead, it means that the provider has agreed to charge a certain rate for their services, which your insurer may or may not cover a portion of. Whether you receive a medical bill from an in-network doctor will depend on factors related to your policy, such as whether you’ve met your annual deductible.

How Can I Tell if a Doctor Is In-Network?

Not sure if a doctor or specialist is considered in-network? Here are the three easiest ways to find out:

  1. Call their office and ask if they accept your insurance.
  2. Access your insurer’s website or online portal to review an updated network list.
  3. Call your insurance company and ask for a list of in-network providers.

While you might live in a town or city that has plenty of doctors, your insurer’s in-network list artificially limits the number of medical providers that you have access to. And even if you are willing to take on the out-of-pocket expenses of seeing a private doctor outside of your insurer’s network, that provider can choose to refuse treatment.

Rural Americans Lack Access to Doctors and In-Network Care

According to the National Association of Community Health Centers® (NACH) more than 100 million people in America either lack access or face critical barriers to accessing primary care—a figure that has doubled in less than ten years.

The number of primary care doctors for both adults and children has been on a steady decline since the 1960s. KFF Health News reports that general practitioners make up only 25% of all doctors in the U.S.

It’s not just family doctors that people are having trouble finding, either. In rural areas, many people live without timely access to specialists (like OB/GYNs and cardiologists), hospitals, and ambulance services.

And even when there are doctors nearby, there’s no guarantee that they will be in-network. Because when there are fewer doctors to choose from, there’s a smaller chance that you’ll be able to find one that is not only accepting new patients but that also accepts your insurance. You may face additional barriers to care if you purchase a health insurance policy that is not compliant with the Affordable Care Act (ACA).

Can My Insurance Company Force Me to Receive Care at an Unqualified Hospital?

Let’s take the example of an individual who lives in a rural area with only two hospitals nearby. One of the hospitals has trauma care or a labor & delivery floor, but none of the doctors accept the patient’s insurance. The other hospital has markedly fewer services with no trauma care and fewer specialists but accepts that person’s insurance.

If that patient needs trauma care or specialized services, their insurer may still refuse to cover the cost of treatment at the out-of-network hospital. Because few people have tens of thousands of dollars to pay for medical bills, this would essentially force that individual to receive care from a hospital that is not equipped to care for them, but that does have a negotiated rate with the insurer.

Exceptions to Out-of-Network Coverage

You can file a formal request called an appeal to ask your insurer to cover the cost of out-of-network medical care. This may be helpful if you need to see an out-of-network provider because:

  • A certain specialist has extensive experience with your specific condition.
  • There are no in-network providers within a reasonable distance from your home.
  • You received emergency care while traveling.
  • There were no other options for a doctor who provided a second opinion.
  • The only hospital equipped to treat you did not have in-network providers.

Every health insurance company maintains its own appeals process. Don’t count on your insurer to make this process easy for you, either. These are big, profit-minded companies that protect their bottom lines by refusing to pay for claims, even those that are clearly in-network and covered by policies.

Fighting for Coverage of Out-of-Network Care

Life isn’t always black and white, and necessary medical care doesn’t always fall neatly into in-network and out-of-network coverage. If your insurer is trying to force you into receiving care from an unqualified hospital or is refusing to help cover necessary out-of-network treatment, you need a powerful advocate on your side.

Matthew L. Sharp has been fighting for patients in Reno, Washoe County, and beyond for more than 30 years. His dedication can be seen time and time again in the results that he secures for clients.

We are proud to offer completely free case evaluations, so contact us today for a 100% no-cost informational meeting.