Committed for Better Business

We’ve all heard the stories of the emergency room claim that cost $10,000 for a broken thumb, or the person who had to file for bankruptcy over the huge bill while using a network outside of their HMO. These stories have been the fuel for arguments about what should be done with our Nation’s healthcare system. The truth is that these stories happen more than most people realize, and many have misconceptions about how this happens. This is why having the right billing network in place is critical to taking advantage of the most favorable default pricing available.

Let’s take a look at a couple of scenarios where one person has a high medical bill and the other is protected. Suppose two people are admitted to an emergency room for the same injury, one with adequate health insurance and the other with none. The ER will know right away that each patient will be billed differently. The person with the right network billing plan will be able to take advantage of a nationwide network, allowing for predetermined prices for most medical conditions she can name. The other will be at the mercy of what the Emergency Department decides to charge. Depending on the medical condition, the difference in what is paid can be more than tens of thousands of dollars. The catch is that to receive this default billing, you must have access to the participating billing network.

When you take a closer look at how these billing networks work, it becomes clear where you may be exposed, especially on smaller networks. No one knows this better than the self-employed and those who don’t get the insurance offered through work. When a person buys health insurance on the exchange (, the only network options available in Texas are HMOs or restricted networks. These networks are formed for the insurance company and the medical institution to share losses, hoping to generate excess patient volume to offset claims. Even these smaller type of HMO networks can have big holes in their billing networks. For example, if a person has surgery within your HMO network, they may still be in for an unpleasant surprise when the final bill arrives. Although your surgeon is likely covered, both the anesthesiologist and the surgical tools rented for the surgery could fall outside the HMO’s billing network, causing the patient to pay thousands of dollars. You guessed it, not a word of warning, just a bill that health insurance won’t cover well after surgery.

The only way to avoid a small HMO network pricing trap is to take advantage of much larger billing networks, allowing you to avoid uncovered traps. These larger networks, or providers, can have millions upon thousands of participating doctors and medical institutions from coast to coast. Many of these national networks mandate that your preferred discount be the primary billing method, protecting the patient’s financial interests from any threat of overpricing. In fact, these predetermined pricing modules are so accurate that some insurance companies formulate your coverage to reflect preferred billing, limiting your out-of-pocket costs by thousands of dollars. Those who use this service can rest easy knowing that their interests will be protected by moving from the correct billing network with unrestricted networks across the country.

Although these billing network giants are elusive in today’s ACA health insurance environment, they exist all over the country, including Texas. In fact, I’ve helped dozens and dozens of clients take advantage of these unrestricted networks in the last few months alone, at much more reasonable premiums than ACA policies. It’s important to consider network billing plans when choosing the right health insurance plan for your family, especially those who don’t qualify for a subsidy (a federal income credit given to people with limited financial resources). It is extremely important to speak with a health insurance professional who has access to these unrestricted billing networks to protect your financial interests.

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