Journalist's Tendon Surgery Sheds Light On Out Of Network Billing


With many insurance companies creating narrower networks for patients in exchange for lower prices, patients are more likely to receive a bill from an out-of-network physician.

Steven Pearlstein, an author from the Washington Post, describes the inside look he gained on out-of-network billing after he opted for an out-of-network surgeon to perform his tendon surgery.

Anthem Blue Cross, his insurance company, agreed to pay “pay 75 percent of the ‘allowable charge’” of his surgery. In reality, the allowable charge was a very small fraction of the $10,000 price tag Pearlstein faced.

The author discovered “The formula used by Anthem to calculate allowable charges is a proprietary trade secret. Or to put it another way, allowable charges are anything Anthem says they are.”

Pearlstein concludes that while rising out-of-pocket costs are a good things because they will make patients more conscious about their health decisions, this will only work “if those prices are reasonable and transparent, rather than part of a sneaky effort by insurers to shortchange their customers. By that standard, Anthem Blue Cross, Virginia’s largest health insurer fails the test — as does a state’s insurance commissioner who seems to be more interested in defending the industry than protecting consumers.”

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