Article Gets it Wrong about Out-of-network hospital Doctors

This article from the Milwaukee Journal Sentinel perpetuates a common misconception about a common problem.

The problem is real enough: you have a PPO. You go to an "in-network" hospital. But it turns out the doctor that treats you is not "in-network". So the charge for that doctor doesn't get the PPO discount, AND the insurance pays it at a lower rate - leading to a much higher charge for you. Often these charges can run into thousands of dollars for an overnight hospital stay. The article is wrong to say the problem is "not widespread". This is the most common problem I heard about when researching consumer PPO woes.

The article perpetuates the myth that people just have to take this treatment, and discusses a proposed state (I assume Wisconsin) "rule" which would require doctors to join the PPO networks. That's wrong on 2 counts:

1. If an insurance company claims in their materials presented to a participant that the participant can go to a particular hospital for treatment at a particular rate, then ALL charges incurred during that hospital treatment should be paid at that rate by that insurance company. I have successfully fought this issue HUNDREDS of times and won every time. It's a simple case of contract adherence: the PPO PROMISED to pay for "in-patient care" at 100% at contracted hospitals. It's in my plan. It's not my problem if they didn't bother to get the right contracts with the doctors - they have to adhere to their contract with me and pay for 100% of my "inpatient care" at that hospital.

2. The state does not need to further burden doctors. Instead, they should go after the problem: insurance companies not abiding by their contracts. Maybe the reason I succeeded at fighting these in the past is that California, where I lived then, had stricter rules about this - I don't know for sure. But if that's the case than other states should do the same.

In any case, if I pay for insurance that promises to pay "100% of inpatient costs" at "in-network hospitals", and if I go to an in-network hospital, the INSURANCE company should abide by their promise and pay the doctors - contract or not.