Choosing Out of Network Doctor

[MadamePresident]

As someone who was prepared to pay out of pocket for the birth of my next child, I would say do what is going to make you most comfortable.

My midwife and birthing center are not in network. However, I was able to ask my doctor to request a gap request. Basically my insurance will cover the cost of my birth at in network rates, since there is not any in network birthing center options in my area.

[AmyRI]

Depends on your coverage and how much you're willing to fight with your doctors.

My plan pays nothing for out of network providers, and we don't have $20k in cash to pay for it. So I would have to stay in-network. Hire a doula. Labor at home as long as possible. Decline the IV.

If you have some out of network coverage, a reasonable OOP max, and you can afford it - I would switch in a heartbeat.

Other things to think about - find out if the practice you're with now is making those rules or if they're the hospital's standard procedure. There are several practices that deliver at the same hospital I gave birth in, but their philosophies vary wildly. The hospital's policies are conducive to natural birthing, but not every OB's are.

[ssmjlm]

Is there any other practices in the area that are in network, but maybe a bit further out?

[Deleted]

They can balance bill you - meaning you have to pay the difference between the MOOP and what they bill - even if you reach the MOOP.

That can open you up to thousands of dollars of liability.

[AmyRI]

Jan 13, 2014 15:21:06 GMT -5 chilerellanos said:

I'm amazed that there's any hospital that makes you lay in bed.

I live in a pretty rural, non progressive area, and the hospital I work at encourages people to get up and move. We have balls, jacuzzis, portable monitors, etc.

I would think (but maybe I'm wrong) that most places would have these things.

I think you're overestimating most places. I have a fairly NB friendly hospital, and they encourage showering and have birthing balls, stools, and squat bars, but they don't have portable monitors (do intermittent monitoring, and you only have to stay near the bed not in it), no tubs at all. There is only 1 hospital I know of in the state with tubs, and they won't allow you to birth in it, only labor.

jjwritergirl, you can call your insurance company and they should be able to tell you the costs negotiated with the different hospitals. I had uncomplicated, short, unmedicated vaginal births with both kids. Hospital stay was 2 days with DS, 1 with DD. Both were in the $16-18k range. I've heard a few thousand more if you get an epi, and at least $5k more if it ends in a c/s (for the actual delivery, and for the extra day postpartum). And these are the rates negotiated with the insurance company. I would count on paying your OOP max.

[CloudBee]

You can bring your own birthing ball, and they can't keep you in bed. You can even pull snacks out of your own bag and eat them, even if they request that you do not.

I would go with the in-network hospital. I was in the hospital for nearly a week (unexpected) and admitted several times prior to my actual delivery.

I would rather forego a few "extras" than be on the hook for thousands. You never know what can happen. And out of network NICU expenses could drown you.

In the moment, a lot of what I thought I wanted, didn't matter, or was out of my control based on my health in the moment.

[Deleted]

Hypothetically speaking, if the birth at the OON birthing center was $100k, you would pay the first $4450, leaving a balance of $95550. Insurance covers 60% of the usual and customary rate thereafter. Imagine the usual and customary rate for the same services at an in-network birthing center is $25,000 - that's all that they pay for the OON center. You have to come up with the balance. The insurance company doesn't just pay $91,000 for a service you could have gotten for $25,000 with a different provider.

[Deleted]

This would 1,000% not be worth the financial risk for me.

[undecidedowl]

If you have the money, I could totally understand going with the out of network practice. But I would add to just remember that it is a total gamble. Even if you switch, you could still end up with a C-section and would have just paid more for it. Do you know anyone who has given birth with your current practice that could tell you about their experience?

My doctor recommended I stay at home as long as possible to avoid most of the downsides of the hospital and it worked for me. By the time I got there, I wasn't interested in the tub or a birthing ball much less eating.

[CloudBee]

Taking the reasonable and customary rates into account is very important when considering out of network care.

There's usually a financial reason why a provider is out of network, and most often that is because they are charging MORE than what's considered reasonable and customary. If you end up with any sort of special interventions, need to see a specialist, spend a few extra days in the hospital, or the baby needs unexpected testing, you could be opening yourself up to a massive debt.

Insurance companies only cover reasonable and customary rates when paying out of network. Thus, if the hospital that's OON charges $10k for a service and the reasonable and customary rates for the area is only $8k, you are on the hook for $2k in addition to the percentage you would pay out of pocket, and again on top of your deductible, etc.

It's really not a chance I would take if your in-network hospital will provide you with a safe place to birth your baby.

[Deleted]

I make my living helping others with insurance. I have a client who, via a teeny tiny loophole in his wife's plan, is on the hook for $80k of balance billed charges from the Mayo Clinic. Bankruptcy is basically his/his family's only option at this point and I would never want someone else put in such a position.

[CloudBee]

Sorry. Me again.

You also don't want finances to play into your decisions in the moment. What if you decide during labor that you want an epi, but are at the out of network hospital and know it will be more expensive. It may be covered in-full as part of your care at the in-network hospital.

I thought I would go med-free, but ended up with an epi.

I couldn't imagine having guilt in the moment because I was getting an "expensive" epi at the out of network hospital. Or foregoing an epi because I know I'll have to pay for all or part of it out of pocket.

Out of network = too much stress.

I think a home birth with an in-network hospital on backup would be LESS stress. And I wouldn't have even gone that route. (Though support anyone who does.) But I would choose home birth over out of network provider any day, because you can leave home and go in-network. You can't just pack up from an out of network hospital in labor and go to an in-network one.

[MadamePresident]

Jan 13, 2014 15:06:47 GMT -5 jjwritergirl said:

Jan 13, 2014 15:02:17 GMT -5 MadamePresident said:

As someone who was prepared to pay out of pocket for the birth of my next child, I would say do what is going to make you most comfortable.

My midwife and birthing center are not in network. However, I was able to ask my doctor to request a gap request. Basically my insurance will cover the cost of my birth at in network rates, since there is not any in network birthing center options in my area.

I didn't know this was something I could ask for. I will look into it. Thank you! To whom did you submit the gap coverage request? 

The gap request had to be submitted by my in network doctor (luckily she is affiliated with the birthing center, so that helped). She called into the insurance and made the referral / request for coverage. Other people with my same insurance company have not had an easy time of it though and have had to request appeals to a no. You will have to have a reason for needing the out of network doctor.

Its not always successful, but its worth a shot if its really important to you.

[CloudBee]

Most people aren't versed in reasonable and customary policies. It's scary. The OOP max only covers what is reasonable and customary.

You're not dumb. You took a smart step by coming on here and asking questions. That's a wonderful thing.

[Deleted]

Jan 13, 2014 15:53:19 GMT -5 CloudBee said:

Most people aren't versed in reasonable and customary policies. It's scary. The OOP max only covers what is reasonable and customary.

You're not dumb. You took a smart step by coming on here and asking questions. That's a wonderful thing.

Exactly.

Going through fertility treatments (which I am so super lucky were covered by my insurance - thank you state mandate!) made me realize how little for each procedure/blood draw/test the doctor actually gets paid. Like each of my IUIs which were billed at $1k+ were paid at like 1/4 of that, thanks to U&C. It is not surprising that a lot of doctors are no longer in-network with the vast majority of insurance plans.

[thebreakfastclub]

I think the "worth" of it really depends on your emotional investment in natural birth. It is not important to me, so I would not open myself up to hundreds/thousands in extra medical bills. A few months later, I barely thought about my birth anymore. I know it is not the same for everyone though.

I ended up with pre-eclampsia at 39 weeks and needed to be induced. I had to lie on my left side and be monitored continuously, as my BP continued to rise. 2 hours of push led to nothing, as my son's head had swelled to the left, stuck in my pelvis, and I needed a C/S.

Not to discourage, but so many things can happen during delivery that are out of your control, that I would not pay extra for an experience I might not be able to get.

You can always have a doula meet you at home and help you labor there for as long as possible, and then accompany you to the hospital to finish.

[jessnpaul]

I wouldn't do it.

We had a ton of unexpected medical expenses due to B being premature and having some issues in which many out-of-network doctors saw him without checking if they were covered by my insurance first. My magical words with the insurance company was "I was in an in-network hospital and had no choice in his care" or else I'd be on the hook for thousands, and i mean THOUSANDS (as in TENS OF THOUSANDS), of dollars. Will this happen to you? Probably not. But not worth the financial risk for a few added perks.

[undecidedowl]

Jan 13, 2014 15:51:19 GMT -5 jjwritergirl said:

I had no idea about the risks beyond the out of pocket maximum. I am so glad I asked! This is making me much more hesitant to switch. I could easily foresee my plan pulling the reasonable/customary card for several line items. I also was dumbly not thinking of emergency NICU costs. Not sure how I skipped that in my calculations. Thank you SO much @mrsspunky and CloudBee for helping with this info! 

undecidedowl I had two friends give birth at the in-network hospital in the last three months. Their experiences are what made me start looking around, unfortunately. But reading the rest of the replies I am starting to think it won't matter compared to the financial risk of switching.

Oh, boo.  Well then in that case, there are lots of tips for getting around some of the annoying procedures.  CloudBee listed some things.  First, I would wait as long as you can before heading to the hospital.  If you are worried about waiting too long, then go ahead and drive to the hospital but just walk up and down hallways or labor in a family waiting area until you are sure you need to check in.  For the IV, you can request a hep lock.  Personally, I wouldn't recommend eating during labor unless it is a very extended labor and then I would do only easily digested foods.  They can ask you not to eat but not really prevent you from eating what you bring.  You can ask for intermittent monitoring to minimize time in bed.

It's just impossible to predict.  By the time I was checked in and taken to my L&D room I was 9 cm and had been up for almost 20 hours and worked a full work day so I ended up opting for the epi.  I never really had a chance to try the birthing ball, tub, etc. 

[havarti]

I think you should stay in network and spend money on an experienced doula.

[pugz]

I do think hiring a doula (find one that has attended births at that hospital) is a good route. Also write up a birth plan and if your doctor approves it, the hospital policies don't really matter that much. If you have permission/blessing from your doctor then the nurses aren't going to push back too much.

It is absolutely your right to refuse an IV, to get up and walk around the room, to get in the shower, etc.

[barefootcontessa]

first I do not think they can make you do anything. I would be very, very clear that I knew all the ins and outs of my policy before I went out-of-network. My first labor ended up in a c-s that lead to some relatively minor complications for me and the baby and the bill was over $30K. Also I will just throw this out there and say I think the concept of a birth experience is overrated. First time around I did all the reading, classes, etc. I went with a doctor who has a 95% vaginal delivery rate and ended up w c-s because I had OP baby who simply would not descent. I spent a lot of time being disappointed afterwards (some was probably the hormones) because of my experience. GL.

[mrshandy]

Great info in here. I'm not very well versed on insurance issues.

But I do agree with a doula and staying home as long as possible. I did this with DS and arrived at the hospital 9.5 centimeters dilated. It was great!

I loved my home birth way more than hospital birth. Birth care was covered by my insurance and the midwives were wonderful. I understand why you wouldn't want to do it. I never considered a home birth for my first. But I almost wish that I could have had both at home.

[curbsideprophet]

Did your friends have the same provider or just deliver at the same hospital? I would look for another in-network provider first. I would be very hesitant to go out of network and I spent a decent amount of money preparing for a pain med free low intervention birth (Bradley classes, birth pool, doula). In the end it worked out, but I knew things could wrong quickly.

[Saudade]

Not only what everyone else has already posted but what happens if you end up with an emergency c/s with many unplanned interventions and you're now talking about *tons* of dollars in increased costs? What happens then?

To me, having been in the above scenario, it would not be worth it AT ALL to take on that risk, even for the differences in services provided.

[magpie]

Can you take a tour of the hospital in question? I know that you have friends who shared their delivery experiences, but maybe better to go see and ask for yourself, just in case it was their specific provider's policy or maybe there were extenuating circumstances that kept them in bed. I just think, since it sounds like you are worried about this, it would be better to go and ask questions directly. Good luck with whatever you decide! I personally would not want the financial risk of going out of network, but I had to be induced for blood pressure and had a long labor with ivs and monitoring, followed by complications and an extra hospital stay. It would have been a nightmare to have had to worry about the extra costs.

[sent]

Jan 13, 2014 16:08:49 GMT -5 jessnpaul said:

I wouldn't do it.

We had a ton of unexpected medical expenses due to B being premature and having some issues in which many out-of-network doctors saw him without checking if they were covered by my insurance first. My magical words with the insurance company was "I was in an in-network hospital and had no choice in his care" or else I'd be on the hook for thousands, and i mean THOUSANDS (as in TENS OF THOUSANDS), of dollars. Will this happen to you? Probably not. But not worth the financial risk for a few added perks.

This is our situation as well.  The hospital is in-network, but all the NICU pediatricians and radiologists that saw our baby were out-of-network.  I nearly fell off the couch when the billing office for the pediatricians said "We are out of network with all insurances except Medicaid."   My first thought was "So you subject patients who might be able to pay out-of-network costs in a situation where I had no choice to pay up to make up for the losses of being a Medicaid provider, when Medicaid patients will pay $0 for the same exact care?"  But the lady further explained that first the office will bill for the care, and then they will file an appeal for the balance saying it was an emergency situation and I had no choice or time to search for an in-network provider.  Then I realized this is a game they probably pay with insurance companies to remain out of network to get them to pay a higher fee than they would've if they were in-network due to the emergency situation of NICU babies.  

However if the insurance company doesn't fall for it, I will face a huge appeals battle and still be on the hook for whatever the Pediatric group decided their time was worth that insurance didn't cover.

[Jalapeñomel]

My answer would be no fucking way. But I had a preemie, and we just saw the bill that went to the insurance company, and it was $125k (and my bill was $27k).

[sent]

Jan 14, 2014 8:58:51 GMT -5 gravytrain225 said:

Jan 14, 2014 3:58:06 GMT -5 sent said:

This is our situation as well.  The hospital is in-network, but all the NICU pediatricians and radiologists that saw our baby were out-of-network.  I nearly fell off the couch when the billing office for the pediatricians said "We are out of network with all insurances except Medicaid."   My first thought was "So you subject patients who might be able to pay out-of-network costs in a situation where I had no choice to pay up to make up for the losses of being a Medicaid provider, when Medicaid patients will pay $0 for the same exact care?"  But the lady further explained that first the office will bill for the care, and then they will file an appeal for the balance saying it was an emergency situation and I had no choice or time to search for an in-network provider.  Then I realized this is a game they probably pay with insurance companies to remain out of network to get them to pay a higher fee than they would've if they were in-network due to the emergency situation of NICU babies.  

However if the insurance company doesn't fall for it, I will face a huge appeals battle and still be on the hook for whatever the Pediatric group decided their time was worth that insurance didn't cover.

I'd be livid.  Are they making you do the appeal or is the hospital handling all of that stuff?

The pediatricians who cover the NICU are their own group and not associated with hospital billing.  The billing office for this group will handle the appeal.  Right now the out-of-network fee they charged the insurance is $688/day with the insurance covering $550.50 and us owing $137.50 per day that she was there, except the first day was more expensive.  She was there 16 days.  I don't know if that is just the pediatrician's part of her stay and if the hospital bills the insurance separately for the stay as well, or if this fee covered everything.  It's like an expensive hotel.  

[leshoequeen]

Our daughter has a rare medical condition and the only providers available are out of network for us. She has a procedure every two months. We're billed around $12,000 for the procedure. Our insurance calls about $300 of that "reasonable and customary" even though we're talking surgery, anesthesia, etc. Luckily our hospital does not balance bill us for the remainder, but even if they did we wouldn't have a choice. Our daughter's condition is life threatening without treatment.