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No one is restricted to a network of doctors or clinics or hospitals if they have PPO Medicare Advantage coverage. They would if they have an HMO but seems like you have to make a change now anyway so it’s a moot point.

Doctors should be but are not always careful about sending patients to labs or outpatient clinics for tests etc. We’ve never been caught in the “non payment” scenario as the MA company requires prior authorization but I guess it could happen. The company we have our MA plans with state on the EOB that such and such a claim was “out of network” so the claim was denied and it is not our responsibility. Big fat zeros for that claim.

A big issue that hasn’t shown up here yet is the “outpatient” vs “inpatient” hospitalization for a Medicare patient. That can be a real can of worms. ALWAYS question if you or a loved one is being admitted as an “inpatient”. Most ER or hospital personnel will understand just why it’s important to ask and to get the answer.

There are cases where a person gets stuck with the entire hospital bill because they were admitted as an “outpatient” - took up bed space in a room for several days, diagnostic tests run up the wazoo and weren’t considered inpatients.

I’ve always asked when my husband has been admitted from the ER to the hospital since I learned about that. Makes for interesting and frustrating reading online...

In our case, hubby had knee surgeries with network doctors, at a network hospital. We thought we had signed all the admitting paperwork in the admitting office. Turns out he was given one additional waiver to sign once he was in the operating arena, and after the IV had been inserted. That waiver was for hubby to acknowledge that the anesthesiologist was a non-network provider. Of course, that piece of paper should have been included in the first set of admitting papers. At the least, informed consent was an issue because hubby was under IV at the time of signing.

When the bill for the anesthesiologist arrived, I was concerned because that service was supposed to be included in the hospital admission. It turns out that the hospital has an exclusive contract with the particular anesthesiology group. Our surgeon even said he had no choice of anesthesiologists... he always had to use the hospital-provided ones.

Upon further investigation, I found the hospital is a 501c3 charity. As they are a public charity, I asked them to provide a copy of their contract with the anesthesiology group. They refused. I mentioned that a call to the authorities might change their mind. I then got a call from the anesthesiology business office informing us that the bill was being reversed, and they were sorry for any "confusion."

This same hospital paid an $11M fine just a couple of years before because they had fraudulently billed outpatient surgeries. Guess they didn't want any scrutiny on their other shady dealings. While the amount of the bill was relatively small, it was the principal that mattered. I imagine most people pay it, grumbling about the non-network cost. But we took them on, and they backed down quickly.