Case of the 
'Boy, I Hate Surprises' -Solved

The answer can be found in Chapter 3, under the button Non-Participating Providers under the WINK.

So, does James have to pay the full amount of the bills? Maybe so.

When you are in the hospital, some of the care that you will receive will be provided by staff that are not employees of that hospital. These caretakers are considered to be outside contractors and they will bill you separately for the services they provide.

James can contact his health carrier and file an appeal requesting that these claims all be paid at the in network benefit level based on the fact that he was not given the opportunity, at the time of his surgery, to select providers that were in his network.

Ultimately, it will be up to his plan to decide if they will pay these claims in network based on this appeal.

Back to Case Study