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Edit: follow-up question w/ resolution info and another billing-related concern.

Recently I broke a finger while playing sports. The finger was clearly broken/disformed. Also I received a minor head wound. Hence I sought emergency services at the nearest hospital. Call it hospital H. Unfortunately H is not part of my health insurance plan/network.

The services I received at H were fairly basic: x-rays of the finger, a splint for the hand and a sling. Also the doctor cleaned the minor head wound. I was at H for about 5 hours (most of which was spent in the waiting room).

I've heard horror stories about receiving enormous bills after receiving treatment from a hospital that's "out-of-network" or doesn't accept one's insurance. Approximately what size bill should I expect from hospital H?

Of course the situation probably varies w/ state (I'm in CA), specific treatment received etc. I wonder if my insurance will cover part of H's bill. This is the first time I've dealt w/ a potentially expensive medical bill so any advice is greatly appreciated.

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To make things worse you will probably get a bill from an out of network radiologist for reading your xrays(yes the ones your doctor already read ~$400) and if they took any blood or other samples you will probably get a bill from the lab. –  user4127 Feb 15 '13 at 15:18
The only way to accurately answer this is to look at the Doctor's bill and your specific insurance policy. We are only going to be able to speculate. –  JohnFx Feb 17 '13 at 7:10
@JohnFx Speculation is ok. I'm just trying to get a very rough estimate as I've never been through this and the anecdotal information I do have comes mostly from sensationalist news sources. –  SundayMonday Feb 17 '13 at 18:11

3 Answers 3

up vote 10 down vote accepted

Several hundreds to several thousands. Hard to answer precisely. But the fact that the hospital is out of network doesn't mean your insurance won't pay. You might have a higher deductible or copay, but it will most likely be covered by your insurance to a significant extent. How significant? You should call your insurance and ask.

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"call your insurance" - indeed. The fact that my policy states 'er visits (for listed emergencies, including broken bones) at out of network facilities are reimbursed at same rate as in network" means nothing to OP. The only thing that matters is how his insurance handles this. –  JoeTaxpayer Feb 15 '13 at 14:55
+1 as charges vary a lot. Read one example at Your coverage is also a factor. As long as you were admitted to the ER, your insurer should cover this on an emergency basis. Depending on your coverage, this can be more than usual out-of-network care. However, you will be responsible for anything not covered i.e. "balance billing". –  JAGAnalyst Feb 15 '13 at 17:18

Some insurance companies may also decide that the wounds you had didn't rise to the level that would require an ER visit, they could decide that some of the charges will not be covered at all. In the end they might cover them, but it will involve many appeals.

The network status can also impact the coverage rate. Assume the hospital tries to bill you $500 for the x-ray, and is out of network. The insurance might have a deal with the in-network hospital to only bill $300 for the x-ray and would have paid 80% or $240, and expect you to pay the hospital the other $60. Because they are out of network the insurance will only cover 60% of the $300 or $180, you would pay $320. The extra $200 may not be counted as part of deductible or out-of-pocket maximum.

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First off, the ACA requires insurers to compensate health care providers for "emergency services" at the in-network rates even if they're out-of-network. "emergency" is defined using the "prudent layperson" standard; if you were an average intelligent individual with no specialized medical training, who upon seeing your injuries thought that you would die or be severely disabled without the care, it's an emergency.

If that is the case, the insurance company will pay the in-network percentage of the bills, after deductible. Usually, they are only required to pay the in-network percentage of the amount they typically negotiate with in-network providers, which can be a significant discount. Because the provider's out-of-network, they have made no agreement to be satisfied with that payment, and can balance-bill you for more than the matching coinsurance you'd otherwise need to pay to an in-network provider.

However, it's doubtful that "emergency care" would fly given the information you provided. A broken finger is not a threat to life, or even permanent disability. Even if the finger was sideways, as long as the bone wasn't showing through the skin, anyone with a general first-aid class under their belt (which is not "specialized medical knowledge") would be able to set and splint it well enough to get you to a visit with your PCP. You could argue for checking out the head wound, but I doubt that will fly either if you never lost consciousness or became incoherent.

In that case, insurers will state, in their summary of benefits, the percentage of costs that will be paid to out-of-network providers, if any. They will also send you an explanation of benefits, detailing what was charged, what the insurer paid, and what's left over. First off, the provider will charge you full price; because they're not in-network, they've made no agreements with the insurer to reduce costs for insured patients. Second, you will likely have to meet your deductible before the insurance company pays anything. I've seen and had employer health plans that required deductibles of up to $5,000 before coinsurance kicked in. I've also seen plans that required higher deductibles when out-of-network care was involved.

So, depending on your deductible, how much you used your health plan prior to that event, what the hospital billed, and what your insurance paid, you could owe, as littleadv said, between a few hundred and several thousand dollars. Ouch, my friend. Let this be a lesson; if you weren't hurt on the job (for which workman's comp typically applies no matter where you go) and it's not so bad that you're forced to take the first available option and can't wait for an in-network provider like your PCP or at least a CareNow, then stay in-network even if it means gutting it up a little more in the interim. Even an in-network hospital stay can be expensive; I went in once for a broken collarbone, and had to pay the ambulance service (city-operated), the hospital copay, a separate copay to the doctor who saw me, and because I didn't meet the deductible, two X-rays to the radiology office which was co-located but not affiliated with the hospital, all separately.

One last thing. Some sports leagues require all participants to purchase supplemental insurance. I had to do this for hockey starting the season after I broke my collarbone. This is typically pretty cheap, like $35 for the whole year, and basically pays out for medical bills above and beyond what's been covered by your primary insurer. You may have this coverage paid for as part of your entry fee into a sanctioned league. Look into it; you could save thousands.

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