What Happens When You Are out of Network: The Insurance Shell Game



Recently Kevin Price, Host of the nationally syndicated Price of Business Show, interviewed Dr. David Wilcox.

Health Transparency: The Real Truth with Dr. David Wilcox 

Every so often when you look at your explanation of benefits (EOB) from your insurance company you may notice that some charges are listed as “Out of Network”. How does that happen and what does it really mean? It means the healthcare entity such as physicians or hospitals do not have a contracted rate with your insurance company.

This means that you will end up paying more for the services that out-of-network healthcare entities provide. It also means that the charges are not applied to your in-network deductible which equates to you paying more for healthcare out of your pocket as the rates for out-of-network charges are much higher than the insurers negotiated rates.

In 2022 the federal government enacted legislation called the No Surprises Act to protect healthcare consumers receiving out-of-network charges. Surprise medical bills happen when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose.

This was a big problem. An example of this was many people who had surgery at an in-network hospital at times received huge bills as their anesthesiologist was out of network and they had no idea. The biggest insurer in the country wouldn’t place certain anesthesia groups in-network as they wanted to contact with their own anesthesiologists to drive down their costs and many times the insurer’s rates were too low for these in-network anesthesiologists. This is why the No Surprises Act was put in place.

So everything should be good now, right? Well, maybe not. A little known data firm helps health insurers make more money when less of an out-of-network claim gets paid by them, often leaving healthcare consumers on the hook for the difference.

What most people are unaware of is there is a data analytics firm called MultiPlan. They work with UnitedHealthcare, Cigna, Aetna, and other big insurers to decide how much out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

The reality is the more they can get you to pay out of pocket the more money the firm makes. They have a hidden financial incentive to cut those reimbursements as much as possible, thus leaving healthcare consumers on the hook for large out-of-pocket healthcare costs. The formula for MultiPlan and the insurance companies is pretty basic. The smaller the reimbursement, the more fees they collect, and this is completely legal and not covered by the No Surprises Act.

A recent New York Times article stated that in 2023 MultiPlan told investors it found nearly $23 billion in healthcare that it recommended not be paid. They do this under the guise of stating that healthcare providers and hospitals are overcharging. In many cases, the fees paid to MultiPlan for processing a claim exceeded the amount paid to healthcare providers who treated the patient. It’s estimated that this type of out-of-network shell game extends to more than 100,000 health plans covering more than 60 million people.

With the No Surprises Act in place, why is this allowed to occur? Most people in America receive their healthcare from employer funded sources which contracts with an insurance company to administer them. These programs are often exempt from state regulations so regulatory entities rarely interfere. The Enforcement of these employer funded programs falls to an agency within the federal Department of Labor which has one investigator for every 8,800 health plans.

This type of methodology amounts to price fixing and ensures profitable fees for MultiPlan and the healthcare insurers from employer funded programs. Just another way to increase the cost of healthcare in the American Healthcare System and cause the healthcare consumer to foot the bill.

This type of information is something that insurers and MultiPlan would prefer the average healthcare consumers are blind to. The American Healthcare System remains complex and that is not an accident. It’s a well thought out business plan by those who stand to make money off of your healthcare.

Remember to do your due diligence when choosing where you will receive your healthcare and whenever possible choose quality in-network providers and healthcare systems to keep your costs down. Always ask for an itemized bill and look at what they have charged you as often times those charges will not be reflective of the care you received.


You can purchase Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival on Amazon at the following link https://lnkd.in/diZKYC2

Follow me on social media at:

Facebook – https://www.facebook.com/Dr-David-Wilcox-102834559130574

Twitter – https://twitter.com/DrDavidHelps

You Tube – https://www.youtube.com/channel/UCyYHs6ttrJ5l6-kUc-lEP9Q


According to a statement, “Healthcare is complex and that is not an accident. It is complex by the healthcare entities vying for your healthcare dollars. Covid has exacerbated the American Healthcare System, which was fragile, to begin with. Many clinicians are leaving healthcare due to burnout. How does the average layperson navigate the complexities of the American Healthcare System where a prescription could cost you $5 at one pharmacy and $500 at another? What does the average layperson do when their insurance company rejects their claim? Proactive education of the American Healthcare System prior to accessing it is the key to safely navigating the healthcare system. Until now, little information has been available to provide the layperson with the knowledge they need to be a better partner in their health care. Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival” is a game-changer and will provide you with the skill set you need to navigate the American Healthcare System.

Website: https://drdavidwilcox.com/

Dr. Wilcox is a Doctorate prepared nurse who also holds a Masters in Health Administration and is Board Certified in Nursing Informatics. Dr. Wilcox has 28 years of healthcare experience in which he worked as a bedside nurse, hospital administrator, and in healthcare information technology which has helped him to develop his unique perspective on the American Healthcare System.

Dr. Wilcox is the author of the book “How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival (2021)” available at https://www.amazon.com/dp/0578878364

Dr. Wilcox currently resides in North Carolina with his wife and their three dogs.

Dr Wilcox’s website: Dr. David Wilcox – Healthcare, American Healthcare System (drdavidwilcox.com)



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