<figure>
 <img src="https://media.eaglewebservices.com/public/2020/1/1578415041999.jpeg" alt="A student practices surgery techniques at Washburn Tech in Topeka. Chris Neal / For the Kansas News Service " />
 <figcaption>A student practices surgery techniques at Washburn Tech in Topeka. Chris Neal / For the Kansas News Service </figcaption>
 </figure>By CELIA LLOPIS-JEPSEN, <a href="https://www.kcur.org/post/getting-health-care-kansas-your-odds-may-be-worse-here-youll-get-surprise-bill#stream/0">Kansas News Service</a>KANSAS CITY, Mo. — Chris Costantini lay in a cold sweat, his shoulder dislocated after slipping on a porch in Kansas City, Kansas.He’d
 been out alone, knocking on doors and rustling up voters for the 
upcoming midterms in October 2018. Now he waited for an ambulance, full 
of anxiety about how the injury could hinder his next performance at the
 Kansas City Ballet.“‘I’m not afraid to admit it was the most 
pain I’ve ever been in,” Costantini recalled. “The shoulder was probably
 out of the socket for about 45 minutes.”A different anxiety 
only began later, when the bills rolled in. That ambulance, it turned 
out, didn’t fall in his insurance network. So Costantini found himself 
on the hook for a $900 bill.Americans frequently get slapped 
with costs for out-of-network services in situations where they never 
had the chance to shop for an in-network option. But research suggests 
Kansans may be especially vulnerable.A <a href="https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/" target="_blank">Kaiser Family Foundation study</a>
 put Kansas in the five worst states for how often patients ran into 
out-of-network providers in 2017 during emergencies or during inpatient 
care at their in-network hospitals.The extra bills that land in their mailboxes often come as a 
surprise, and pile onto in-network medical costs that already have 
patients’ heads spinning.Costantini’s emergency led to more than
 $6,000 in in-network charges alone, for the hospital and doctor. His 
insurance company’s pre-negotiated rates knocked those charges down to 
less than $2,000.He tackled that and the ambulance in more manageable monthly increments, counting his blessings that he could afford it.“Perversely, I feel lucky,” Costantini said. “You would think that we wouldn’t have to feel lucky.”<h2>The ‘black box’</h2>Kaiser
 tapped a database with claims for 19 million people nationwide who got 
their health insurance through large-employer plans.Nearly one 
in five emergency care visits meant running into a doctor or someone 
else outside a patient’s network. The situation was only slightly better
 for inpatient care at in-network hospitals.But those figures 
mask a more complex picture: The situation varies widely by state. While
 Kansas fell at the bottom of the pack, neighboring Nebraska rose to the
 top.What explains higher out-of-network rates in Kansas? Experts aren’t sure.Hospitals and billing are “very much a black box,” said Karen Pollitz, the study’s co-author.That
 complicates research. And patients wonder whether they’ll make it out 
the hospital door without bumping into an out-of-network assistant 
surgeon or radiologist.“It just feels like a minefield, you know,” Pollitz said.Nationally,
 experts know some hospitals are far worse than others, though it’s 
difficult to pinpoint the culprits behind wide regional and even local 
disparities. And situations can vary year by year, as insurance networks
 change, as hospitals buy up physician groups, or as new staffing 
companies land on the scene with business models built around aggressive
 billing.The Kansas Insurance Department doesn’t oversee the nitty-gritty 
details of insurer-provider contracts that might shed light on Kaiser’s 
analysis of Kansas claims. The kind of private insurance studied by 
Kaiser overwhelmingly falls under federal, not state, law.<h2>Where logic fails</h2>Patients
 often don’t realize they’ve received out-of-network services until an 
extra bill arrives from a provider they never chose.“The 
anesthesiologist is who’s on call when you show up,” Pollitz said. “If 
you’re having cancer surgery, you’ll never meet the pathologist who 
looks at your slides.”Laura Burton made the common assumption 
that the doctors walking the halls of her in-network hospital in Topeka 
work for that hospital and fall in the same network.“Absolutely,” she said. “One hundred percent, that’s what I believed.”Then
 came a letter from a Michigan mailing address demanding $400 for a 
pediatrician employed by an external staffing firm who checked on baby 
Amelia soon after her 2014 birth.“It was not something we could 
pay off off-hand,” Burton recalled. “Who would ever anticipate that a 
random physician would come in who wouldn’t be covered?”After a 
pregnancy full of complications, her bills surpassed her deductible and 
out-of-pocket maximum well before labor. She and her husband went into 
the final stretch thinking delivery wouldn’t cost more. They paid off 
the unpleasant surprise gradually.A <a href="https://www.federalreserve.gov/publications/2018-economic-well-being-of-us-households-in-2017-dealing-with-unexpected-expenses.htm" target="_blank">Federal Reserve</a>
 survey found an unexpected $400 bill would cause problems for 40% of 
U.S. adults, making them borrow money, sell property or fall behind on 
credit card debt. And surprise bills are, by definition, impossible to 
plan for.“It’s a really frustrating, powerless feeling for 
patients,” said Chris Garmon, an economist at the University of 
Missouri-Kansas City who previously worked on antitrust investigations 
at the Federal Trade Commission. “The more things that are done to you 
in the hospital, the more likely you are to encounter an out-of-network 
provider.”<figure>
 <img src="https://media.eaglewebservices.com/public/2020/1/1578414966600.jpeg" alt="Credit Chris Neal / For the Kansas News Service" />
 <figcaption>Credit Chris Neal / For the Kansas News Service</figcaption>
 </figure>Even a brief drop-in to someone’s room can lead to a hefty surprise bill.“That’s called drive-by doctoring,” he said. “That’s a real source of this.”<h2>In search of a solution</h2>People
 like Burton in Topeka have done things right, said Jack Hoadley, a 
health policy researcher and professor emeritus at Georgetown 
University. They got insurance and went to an in-network hospital.Yet none of that helps if the pediatrician who pops by has no deal with your insurer.“You run into a situation that — how do you control?” he said.Experts warn that some providers — such as hospital staffing companies <a href="https://khn.org/news/investors-deep-pocket-push-to-defend-surprise-medical-bills/" target="_blank">backed by private equity funds</a>
 — avoid joining networks to cash in on the lucrative world of surprise 
billing. That lets them charge more than the rates negotiated by 
insurance companies.A Stanford University analysis of millions of insurance claims found <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740802?guestAccessKey=9fba6e0c-f029-401a-9675-737db3e67b5d&amp;utm_source=For_The_Media&amp;utm_medium=referral&amp;utm_campaign=ftm_links&amp;utm_content=tfl&amp;utm_term=081219" target="_blank">more than 80%</a>
 of ambulance rides fell outside patients’ insurance networks. New 
research from Yale University, meanwhile, estimates that reining in 
out-of-network billing by anesthetists and others could cut health care 
spending by <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00507?utm_campaign=MEDIA+ADVISORY%3A+Cooper+AOP+12-16-19&amp;utm_medium=email&amp;utm_content=From+Health+Affairs%3A++The+Cost+Of+Out-of-Network+Billing+For+In-Network+Hospital+Care&amp;utm_source=Newsletter" target="_blank">tens of billions of dollars</a> annually.“It’s
 (a problem) that jumps up and bites people for a significant amount of 
money that they can’t afford,” Hoadley said, “And it’s one that that is 
fixable.”<a href="https://khn.org/news/congress-compromise-legislation-on-surprise-medical-bills/" target="_blank">A recent push in Congress</a>
 has advocates hopeful that 2020 could finally bring a federal solution,
 though details remain up in the air. Surprise billers have pressed 
Congress not to curb charges too much.Meanwhile, half of states —
 red and blue alike — didn’t wait for a federal fix. They’ve passed some
 level of consumer protections against surprise bills.Kansas hasn’t. And though it might be especially useful in a state where the ACA health exchange <a href="https://www.kcur.org/post/kansans-have-more-options-ever-2020-aca-marketplace-read-fine-print#stream/0" target="_blank">offers only plans that are particularly unhelpful</a> for out-of-network care, advocates say action in Washington, D.C., is the ideal.State laws can’t help most people with private insurance through work, for example. Only changes to federal law can.Celia
 Llopis-Jepsen reports on consumer health and education for the Kansas 
News Service. You can follow her on Twitter @Celia_LJ or email her at 
celia@kcur.org. The Kansas News Service is a collaboration of
 KCUR, Kansas Public Radio, KMUW and High Plains Public Radio focused on
 the health and well-being of Kansans, their communities and civic life.

Odds may be worse in Kan. for surprise medical bill