RESOURCES

Reining in out-of-network health care costs

 

By Brad Anderson
CEO, Naviguard

The following was inspired by this article in The Wall Street Journal, in which Matthew Vesledahl, chief affordability officer and senior vice president at UnitedHealthcare, discusses ways to make health care more affordable.

KEY TAKEAWAYS:

  • Receiving care from an out-of-network provider is sometimes unavoidable or desired
  • Naviguard® helps people avoid paying too much for out-of-network care
  • Reining in these costs may help make out-of-network care more feasible for people

What employees and employers should know

Infographic of balance billing in the U.S. statistics

Infographic transcript

Balance medical billing in the U.S.

33% of those who receive an unexpected medical bill say the amount was over $1,000.1

More than 45% of all Americans worry that a major health care event will wipe out their savings & bankrupt them.3

 

Expecting the unexpected

Those eye-opening facts underscore the fears and challenges many people face dealing with the complicated health care system and its costs, especially the cost of out-of-network medical providers. Here are three examples where balance medical billing may occur. Keep in mind a balance bill is the difference between the provider’s charge and the amount allowed by your plan.

Example #1: Lab services are ordered from an out-of-network lab

Suppose you visit an in-network provider for a routine checkup, and during the visit they order lab services. Unknown to you, the provider sends the lab work to an out-of-network lab. As a result, you receive a balance bill from the lab, which is significantly higher than what you expected.

In this example, the lab provider charges $2,371 for lab services. But your insurance plan only allows $558. As a result, you could face a balance bill amount of $1,814.

Infographic that shows how balance billing might result from lab tests

Infographic transcript

Average costs for lab tests

  • Out-of-network lab provider’s billed amount: $2,371.132
  • Insurance plan allowed amount: $557.532
  • Potential balance bill amount: $1,813.602
Example #2: Using an out-of-network ground ambulance

Imagine you’re cleaning your gutters and accidentally fall off a tall ladder, resulting in an injury that needs immediate medical attention. An ambulance is called, and you’re taken to the emergency room. If the ambulance provider is out-of-network with your insurance plan, you may face an unexpected and substantial balance medical bill.

In this example, the ground ambulance provider bills you $3,089.34. However, your insurance plan only allows $1,103.62. As a result, you could potentially face a balance medical bill amount of $1,987.46.

Infographic that shows how balance billing might result from ground ambulance services

Infographic transcript

Average costs for ground ambulance services

  • Ground ambulance provider’s billed amount: $3,089.342
  • Insurance plan allowed amount: $1,103.622
  • Potential balance bill amount: $1,987.462
Example #3: Seeing a provider who is no longer in-network

Imagine you’ve been seeing the same behavioral health provider for several years, and they’ve been covered by your insurance plan. However, the provider is no longer included in your plan's network. If you choose to continue seeing this provider, you may receive a balance bill for their services since they are now considered out-of-network.

In this scenario, the behavioral health provider bills you $4,623.25 for their services. However, your insurance plan only allows $602.83. As a result, you could face a balance bill amount of $4,020.48

Infographic that shows how balance billing might result from behavioral health services

Infographic transcript

Average costs for behavioral health services

  • Out-of-network behavioral health provider’s billed amount: $4,623.252
  • Insurance plan allowed amount: $602.832
  • Potential balance bill amount: $4,020.482

Our three-legged stool

Helping employees and employers manage out-of-network balance medical bills is why Naviguard exists. We’re a UnitedHealthcare service that uses advanced analytics, and effective strategies to review and resolve out-of-network balance medical bills.

I’m happy and humbled to say we’re good at this and we resolve the great majority of out-of-network bills we’re asked to review. Our experts have decades of health care experience and use reference-based pricing and provider network knowledge — all to resolve out-of-network balance medical bills. Those fundamentals are the three legs that support our sturdy stool.

The 3 fundamentals of Naviguard's approach

Infographic transcript

The 3 fundamentals of our approach

  • Expertise
  • Reference-based pricing
  • Provider network knowledge

Why we do what we do

For situations in which people choose to go out-of-network — maybe because they have a great relationship with a doctor or simply don’t have an option — the amount they owe may still be a big surprise. 

So, in addition to working with members who receive unexpected out-of-network bills, we help those whose out-of-network balance medical bills are expected but may still seem excessive or complicated. 

We believe health care is vital and should be available to everyone, and that the cost should not be catastrophic. Our goal is simple: to help you avoid paying too much for out-of-network health care.

At Naviguard, nothing means more to us than helping people avoid having to pay excessive health care bills. That’s why we’re here, and why we do what we do.

Brad Anderson is the CEO of Naviguard and has held numerous senior-level positions in the health insurance industry.

 

RESOURCES

REFERENCES

  1. "Data Note: Public Worries About and Experience with Surprise Medical Bills." KFF.org, February 28, 2020. Lopes, Lunna, Audrey Kearney, Liz Hamel and Mollyann Brodie.
  2. Naviguard Data, March 5, 2023 – March 5, 2024
  3. "Americans Fear Personal and National Healthcare Cost Crisis." Gallup Blog, April 2, 2019. Mike Ellrich and Lance Stevens. 

 

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