HOUSTON — You’ve got insurance and go to a covered hospital for medical care.

So how can you be stuck with out-of-network charges or the balance of the bill that’s often hundreds or thousands of dollars, even after you followed the rules of your insurance company and your doctor?

Balanced billing is a national issue that has likely already cost you or someone you know money.

Playing games is usually a fun family pastime, but not always. The ElShenawys said they were caught in the middle of a bad health care game.

Last October, Rania had a bad reaction to some medicine and went to a Memorial Hermann Hospital emergency room. 

Her insurance company paid, but then months later it notified her the emergency room doctor was not in-network, and they wanted her to turn over $425.

The physician’s daughter spent months arguing with her insurance provider — Principal Financial — before contacting 11 News. It turns out this is just one example of a much larger problem.

“To tell a patient you can go to XY hospital and you’re covered is not truth,” Texas Medical Association spokesman Dr. Michael Speer said. “It’s little truth.”

Doctors worry insurance companies save money by having inadequate network coverage, particularly for certain specialties.

As a demonstration, Dr. Speer went thru United Healthcare’s Web site, searching for covered pathologists at local hospitals.

“Only one pathologist is in that network’s plan,” he said.

Insurance companies argue some doctors try to hold them hostage for exorbitant payments. Either way, it’s not unusual for you to go to your covered hospital and see a doctor who’s not, as the ElShenawys found out again.

Rania’s case was still unresolved when Mohamed got a severe infection in March. Because of all the previous problems, the computer programmer insisted on seeing his in-network family doctor first.

“My family doctor literally said I am crazy to be here, and he referred me to ER immediately and he actually called them, called the ER to expect me, because it was quite serious,” he said. “And they kept me overnight.”

It was all documented. On top of that, the ELShenawys specifically asked Memorial Hermann to see an in-network physician.

“Because of all the problems that happened to us, we actually do that now, but it doesn’t help,” he said.

The Texas Hospital Association acknowledges that even if you’re smart enough to ask for in-network doctors, it may not happen.  

“There is room for improvement,” they said. The problem? Everything from administrative hassle to a lack of covered doctors. 

Principal Financial’s diagnosis in Mohamed’ case?  The emergency room doctors were not in-network, and he did not have a true emergency.

Mohamed was livid.

“I felt someone putting a gun to my head; ‘pay this or we’re gonna ruin you credit history,’” he said.

On June 11, their letter said “no additional benefits paid” towards the $678 bill.

Two days later, 11 News contacted the company for this story, and June 16, Principal Financial sent a new letter saying it would pay.

But Mohamed still worries about those who choose not to fight back.

“There is literally millions or billions of dollars being paid out of pocket by patients because they just don’t know any better, they don’t have time or don’t want to go through hassle,” ElShenawy said.

For this family, health care has become a stacked game with no clear rules.

Texas lawmakers and Department of Insurance are actively working on the problem. A recent bill offers some protection against credit agencies in these cases, and a major study is under way now to determine physician network adequacy.

REPLY FROM PRINCIPAL FINANCIAL

SONJA SORREL - PUBLIC RELATIONS

11 NEWS: If an insurance company covers hospitals, why not cover the physicians as well?

PRINCIPAL FINANCIAL: Networks contract with hospitals and providers who practice in those hospitals separately. Each provider decides whether he/she wants to become a member of a given network. We still pay benefits to a non-participating physician; we just don’t pay as high a level of benefit had the physician been a participant in the network.

11 NEWS: How do you determine if there are enough physicians in a particular network?

PF: We have guidelines in place and evaluate each network to ensure we offer sufficient numbers and types of providers. Our guidelines were set based on evaluation of several state requirements and generally accepted industry standards for access. We also look at each network by county to determine the availability of specific types of providers. Finally, we run reports to evaluate network versus out of network utilization and use this information to request additional providers by specialty type and market.

11 NEWS: How are you supporting transparency?

PF: We support transparency in a number of ways, but mostly through the services available on our member Web site. These include things like a treatment cost estimator, physician selector and coverage adviser. In addition, through our care management program, we work closely with individuals who have certain medical conditions to ensure they better understand their health and healthcare. I can provide more information on any of these topics if they are of interest.

11 NEWS: Have you considered using SmartCards to provide real time insurance coverage information?

PF: We feel strongly that development and usage of healthcare technology is critical to improving quality and safety as well as controlling the cost of health care. We’ve looked into SmartCards and continue to evaluate, but we have not implemented them at this point.