Don't be surprised by non-network providers at network hospitals

At some network hospitals, emergency room and specialty services (such as radiology and anesthesiology) are being delivered by providers that aren't contracted with Aetna. This practice can have serious financial consequences for patients.

The Aetna Choice POS II network is a preferred provider organization (PPO). It allows Aetna to negotiate fees with health care providers and make those discounts available to health plans, such as the Carpenters Health and Security Plan. The discounts are passed along to participants and dependents when they need medical services and supplies, but only when receiving care from network providers.

Different providers, different rules

If a network hospital contracts a non-network provider to provide services, the non-network provider is not obligated to discount fees for Aetna members. For the most part, the non-network provider can charge as much as he or she wants.

However, when the non-network charges are submitted to the Carpenters Health and Security Plan, benefits will be limited to the maximum allowable fee for the covered service. If a charge exceeds the maximum allowable fee, the provider can bill the patient for the portion not covered, in addition to the normal coinsurance (i.e., the patient's share of charges allowed by the plan).

What can be done?

If you are billed for non-network services at a network facility, call Carpenters Trusts and speak with a Claims representative (800-552-0635). We'll need a copy of the provider's billing statement before we can contact the provider to resolve the issue. We cannot guarantee that the issue will get resolved, but we will do our best to negotiate a reduction. We will pay the claim at the network percentage (90% instead of the usual 80% for covered services) but only for the amount allowed by the plan (i.e., maximum allowable fee).

Obviously, this makes out-of-pocket expenses harder to predict. Because of the uncertainty, participants and dependents might consider avoiding hospitals that engage in this practice. Below is a list of hospitals that use non-network providers.

State City Facility
ID Blackfoot Bingham Memorial Hospital
ID Caldwell West Valley Medical Center
ID Coeur d Alene Kootenai Medical Center
ID Idaho Falls Eastern Idaho Regional Medical Center
ID McCall St. Luke's
ID Moscow Gritman Medical Center
ID Nampa St. Alphonsus
ID Orfino Clearwater Valley Hospital
ID Pocatello Portneuf Medical Center
ID Sandpoint Bonner General Hospital
MT Anaconda Community Hospital
MT Great Falls Benefis Hospital
MT Missoula St. Patrick's Hospital
WA Aberdeen Grays Harbor Community Hospital
WA Anacortes Island Hospital
WA Arlington Cascade Valley Hospital
WA Auburn Auburn Medical Center
WA Bellingham S.t Joseph Medical Center
WA Bremerton Harrison Medical Center
WA Centralia Providence Centralia Hospital
WA Ellensburg Kittitas Valley Hosp
WA Enumclaw St. Elizabeth Hospital
WA Ephrata Columbia Basin Hospital
WA Federal Way St. Francis Hosp
WA Gig Harbor St. Anthony Hosp
WA Issaquah Swedish Issaquah
WA Issaquah Swedish Lake Sammamish
WA Kennewick Kadlec Medical Center
WA Longview St. John Med Ctr
WA Mill Creek Swedish Mill Creek
WA Moses Lake Samaritan Healthcare
WA Newport Newport Hospital
WA Olympia Capital Medical Center
WA Pullman Pullman Mem Hosp
WA Puyallup Good Samaritan Hospital
WA Richland Kadlec Regional Med Ctr
WA Seattle Swedish Ballard
WA Seattle Swedish Medical Center
WA Sedro Wooley United General Hospital
WA Spokane Deaconess Hospital
WA Spokane Holy Family Hospital
WA Spokane Providence Sacred Heart
WA Spokane Valley Hospital
WA Sunnyside Sunnyside Hospital
WA Tacoma St. Clare Hospital
WA Tacoma Tacoma General Allenmore
WA Tacoma Tacoma General Hospital
WA Toppenish Toppenish Community Hospital
WA Yakima Yakima Regional Medical Center
WY Cheyenne Cheyenne Regional Medical Center
WY Rock Springs Memorial Hospital of Sweetwater Co.