Your Protections for Out-of-Network Emergency Services and Surprise Bills

There are circumstances when you may unknowingly be treated by out-of-network doctors. Typically this occurs during a hospital admission (inpatient or outpatient, emergency or nonemergency) when services are provided by out-of-network doctors — even if the hospital is an in-network hospital and/or some of the other doctors are in GHI’s provider network.

For example, during an emergency room hospital admission, you may be treated by a plastic surgeon who works at an in-network hospital, but is not in GHI’s provider network; you will be responsible for the surgeon’s bill after GHI reimburses from its Schedule. Or, during a scheduled out-patient procedure, even when the hospital is an in-network hospital and the doctor performing the procedure is an in-network doctor, you may also receive services from an out-of-network doctor who works at the hospital, such as an anesthesiologist, radiologist, or pathologist, but is not part of GHI’s provider network. Even though that doctor works at an in-network hospital, if the doctor is an out-of-network doctor, you will be responsible for your out-of-network cost sharing and the balance of that doctor’s bill after GHI reimburses at the rate from its Schedule.

However, for services rendered on or after April 1, 2015, you will be protected from out-of-pocket costs, other than applicable in-network cost-sharing, for services that qualify as “surprise bills” or emergency services as described in the Out-of-Network Cost Notice at the front of your Certificate of Insurance.

In the event that the protections set forth in that document do not apply, your out-of-pocket expenses may be substantial, since the out-of-network doctors will be covered under your provider benefits the same as any other out-of-network doctor, in many instances.