âHe told us to go home, get packed and get to the hospital, where they will be waiting for us,â Ms. DâAndrea said. âThat was very shocking, but we did it.â  There was little time to think about the intricacies of their insurance plan, but Ms. DâAndrea knew she had already selected a comprehensive plan a few years earlier. She gave her insurance card to the hospital staff, but her daughter, Sienna, was ultimately treated by several doctors who were not in their planâs network.  âWe assumed that because we showed them our insurance card and nobody had any objections, we were covered,â said Ms. DâAndrea, 35, of Farmingdale, N.Y. âBut I also wasnât in the mind-set to ask, or to have them stop doing heart surgery on her.â  Sienna left the hospital in early March, two weeks after a successful operation repaired her aorta. But she had a rough road ahead. She went home with a feeding tube in her nose.  And just a few weeks later, after vomiting through the night, she spent another 17 days in the hospital. As the family finally arrived back home in mid-April, piles of bills from out-of-network doctors started to roll in.  Itâs not uncommon for patients who visit an in-network hospital to learn later that theyâve been treated by out-of-network providers, resulting in thousands of dollars in charges. And while the Affordable Care Act generally caps what consumers must spend out of pocket when using providers within their planâs network, it doesnât protect consumers from large bills from outside providers. Those providers may be free to charge the consumer for the balance of the bill that the insurer did not pay, known as âbalance billing.â  âWhen the doctors work in the hospital, not for the hospital, which is often the case, theyâre not obliged to join the same networks as the hospital,â said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. âAnd patients generally have no say in selecting those doctors. Sometimes the patients donât even see them â for instance, if their X-rays get sent to a radiologist or their tissue to a pathologist,â patients wonât even know the name of that doctor until the bill comes.â  This generally happens because the hospitals donât always assign doctors to the patient. Individuals may begin treatment with a doctor who accepts their insurance. But if that doctor refers the patient to another specialist, or works with an anesthesiologist who isnât in the network, the patient is likely to end up with a bill from that provider, said Gerard F. Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University Bloomberg School of Public Health. âAbout the only thing you can do is to go to a hospital where the M.D.âs are all hospital employees,â he added.  Some states limit the amount that out-of-network hospitals and doctors can charge above what insurance has covered, experts said, but there are no federal curbs on balance billing. The new health care law, does, however, offer some protections for people who need emergency care: insurers cannot charge more for co-payments and co-insurance for emergency services than they would charge when you use in-network providers. Insurers must also pay out-of-network emergency providers according to a standard schedule, in hopes of lessening the likelihood that patients will be left with enormous bills.  Still, thereâs nothing in the law that stops health care providers from billing consumers for the balance, which is what often happens â and exactly what the DâAndrea family experienced. âThis is not an issue that the Affordable Care Act fixes,â said Timothy S. Jost, a professor at the Washington and Lee University School of Law and expert on health care laws. âIt is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do.â  If consumers use providers within their network, their annual out-of-pocket costs will vary depending on the type of plan they choose (bronze, silver or gold, for example) and their household income. But the new law states that those expenses cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. (This is true for all plans bought on the exchange, and for many individual plans.)  So what sort of recourse do consumers have when they receive big bills from out-of-network providers? The first step is to make sure your insurance plan paid what it should have, since many plans provide some coverage for out-of-network services. And if you were treated for an emergency service (in an emergency room or an extension of it), make sure the insurer paid at least what they would have paid to an in-network provider, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group. Consumers should also check to see if their state has any additional protections against balance billing. Finally, consumers should talk to their providers about reducing any remaining charges.  Consumers would do well to follow the lead of Ms. DâAndreaâs mother, Livia Cooper. The couple relied on her to deconstruct and analyze the reams of invoices that arrived in their mailbox â including a collection notice â since they were busy caring for Sienna.  Ms. Cooper spent countless hours poring over the bills, trying to make sense of it all. âIt was so overwhelming,â said Ms. Cooper, who had to close the womenâs boutique she ran with Ms. DâAndrea so they could focus on Sienna, who is now 9 months old. âWe received department bills and there could be 60 invoices on one printout. You would have a bill for $8,100 from one department or $6,500 from another department. It was hard to figure out what was covered, what wasnât covered and what was balance-billed.â  The billing service for the doctors initially wanted the DâAndreas to enroll in its budget plan, which Ms. Cooper refused to do before figuring what the couple actually owed. Her persistence ultimately paid off. She finally reached a supervisor in the billing department and explained that âwe had insurance, were paying the co-insurance, co-payments and deductibles, and could not afford to pay any more than what we were obligated,â she said. She also pointed out that the providers were paid what they would have been paid if they were in the network.  As a result, many of their bills were reduced, and some were forgiven. The surgeon who repaired Siennaâs heart was in the planâs network, for instance, but the assisting surgeon was not. And even though the insurer paid the assisting surgeon the same amount as the main surgeon, Ms. Cooper said that the couple was billed for $4,100, or the balance not covered by insurance. The billing department asked the couple to file an appeal with the insurer, which they did. As a result, the insurance company paid an additional $700 and the surgeon wrote off the balance.  Ms. DâAndrea and her husband, who operates a small entertainment and D.J. business and also refurbishes homes, ultimately paid about $10,000 in out-of-pocket expenses, Ms. Cooper estimates.  Since the coupleâs current health plan will terminate at the end of the year, they are now trying to choose a plan on the New York exchange that includes Siennaâs doctors â another tedious process. âSiennaâs situation is such that it makes us very nervous,â said Ms. Cooper, who is helping the couple research various plans. âYou donât know who the doctors are on different plans because there are no lists.â  As my colleague Abby Goodnough reported earlier this week, many of the state-run exchanges do not have provider directories or search tools on their Web sites â at least not yet â so customers cannot easily check which doctors and hospitals are included in a particular planâs network.  And even though the DâAndreas could not have known that out-of-network doctors were treating their daughter, it underscores how important it is to ensure all of their providers will be on the plan they ultimately choose. âBasically, if youâre out of network,â Ms. Cooper said, âyouâre out of luck.â
Consumers may face big payments to doctors who participate in their care, in an emergency or in a hospital, but are not in their insurance network.