Surprise Billing and The Real World

The consequences of surprise billing issues are worrisome for laypeople.

Sadly, about a month ago my wife broke her arm. She slipped while carrying a box when she was helping with a baby shower.

We went to the emergency room at Mount Sinai Medical Center in Miami (shameless plug: they were great). Since Mount Sinai is a participation provider in our health insurance plan, the emergency room services were performed by an outside physicians’ group and were covered under the No Surprises Act, meaning the physicians’ group can’t balance-bill us for their services. Whether or not Mount Sinai was a participating provider, emergency services are still covered under the related No Surprise Billing Act.

Now comes the tricky part. The hospital told us that she needed to see an orthopedist after putting a cast on her arm. We got the name of an orthopedist who had staffing privileges at Mount Sinai. We scheduled an appointment at her office, which was in a medical office building next to another hospital in our network. All good, you would think, under the Surprise Billing Act; we can’t be balance-billed. Bad news: she needs a plate in her arm, and a surgery is scheduled. We are very surprised when, on the day of the surgery, we are informed that unless we pay a $1,392 co-pay, the surgery will not happen. My wife is in great pain. We pay the co-pay.

After the fact, I found out that the orthopedist was not in my network, and that the bulk of the co-payment was because we were charged at the “out-of-network” rate.

Since the physician worked at two hospitals in my network, and the operation happened in a building adjacent to one of them, how did this not violate the Surprise Billing Act?

While the physician office was indeed next to a participating hospital, it was not in the hospital. While the physician practiced at another participating hospital, the service wasn’t performed in that hospital.

I did file a dispute on the charge. Being a consultant, I have resources, and I may get some of my money back. My question is whether the average patient would have any recourse – or even know to complain?