You might expect to pay more if you choose a doctor outside your insurer’s network. But what if you don’t know a doctor’s status — or are in no position to ask? The result can be a nasty surprise known as balance billing.

Insured patients are sometimes hit with unforeseen charges after emergencies, when they are taken to the closest hospital regardless of whether the facility accepts their insurance. Consumers also may be billed after visiting in-network hospitals if they received treatment from medical providers who work there but don’t participate in the same health plans. When that happens, insurers often pay part of the doctors’ fees, and the physicians bill patients for the difference. This is the practice known as balance billing, and it can leave consumers battling both the insurer and the medical provider to get the charge reduced.

Tom Pritchard, of Hartwick, N.Y., knew the orthopedic surgeon who operated on his hand last December was in his insurer’s network. So was the outpatient surgery center. But when a bill arrived weeks later, he got a surprise: The anesthesiologist didn’t accept his health plan. After Mr. Pritchard’s plan paid the specialist at its out-of-network rate, the anesthesiology practice asked the 57-year-old retiree to pony up the remaining $580.

So far, Mr. Pritchard says he has refused to pay, because he’s upset no one warned him or gave him a chance to request an in-network doctor. “It never occurred to me to ask” about the anesthesiologist, he says. “Why would I?”

A growing number of state regulators are moving to crack down on balance billing. Mr. Pritchard testified in October at a public hearing held by the New York State Insurance Department, which is drafting proposed regulations that could force more disclosure by medical providers and insurers and shield consumers from unexpected charges. California regulators recently made it illegal for people covered by health-maintenance organizations to be balance-billed for out-of-network emergency services. And late last year Illinois put out a bulletin that protects many consumers from balance bills in certain situations if they make a “good faith” effort to use in-network doctors.

Alamy

Insured patients may get hit with big bills from out-of-network health-care providers, even if the situation was an emergency.

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Online Resources

If you’re faced with an unexpected bill from a health-care provider seeking the difference between his fee and what your health plan paid, you should start by calling your insurer and the doctor’s office. If you can’t resolve the matter, you may want to turn to a consumer advocate for help.

Families USA offers links to state-based advocacy groups and state-government health advocates.

• The Patient Advocate Foundation is a nonprofit.
• Here are some companies you can hire. patientcare4u.com, healthproponent.com, healthcareadvocates.com, healthchampion.net
• States have different rules governing balance billing, which may protect you. This site has links to state insurance regulators you can call.
• Here is information about some recent regulatory actions in California, Louisiana and New York (scroll down to the Oct. 7 hearing).

“The patient shouldn’t have to bear that burden,” says Michael McRaith, director of the Illinois division of insurance. He says the problem may be growing partly because some doctors are feeling squeezed by insurers’ reimbursement rates, prompting them to drop out of networks and bill patients instead.

It’s not clear how much balance billing occurs in the U.S., but the practice appears to be widespread. A state survey last year by the California Association of Health Plans found that 16% of insured respondents who had visited an emergency room in the previous two years had been balance-billed. Based on that, the group estimated that 1.76 million Californians had faced such charges for emergency room visits in that period, with amounts averaging $300 each.

Physician groups say doctors have the right to refuse to sign up with insurers’ networks, and regulators shouldn’t bar doctors who don’t participate in health plans from billing insured patients. They say that insurers’ payments to out-of-network health providers are often unfairly small. “You can’t turn it around and say it’s the doctor’s fault,” says Nancy Nielsen, president of the American Medical Association.

Insurers Defend Payouts

Insurers counter that they shouldn’t be forced to pay whatever fee out-of-network health-care providers demand. “You have a set of specialists who won’t contract with health plans, and they want to bill whatever they choose,” says Robert Zirkelbach, a spokesman for America’s Health Insurance Plans.

Insurers also defend how they calculate payments they make to out-of-network doctors and hospitals. The size of the payments, known as reasonable-and-customary fees, is often derived from a database of medical-claims price information. Still, the New York attorney general’s office is investigating the legitimacy of insurers’ methods.

Ronald Eckert, a Las Vegas casino employee, says he can’t afford to pay the approximately $8,200 charge from an out-of-network surgeon who operated on his fractured eye socket after he fell last year. Mr. Eckert says that when he arrived in the emergency room he asked a nurse to call his health plan and check for coverage. But by the time the surgeon came to his room, the 59-year-old says, he was semi-conscious and not in any condition to confirm that the doctor would accept his insurance.

“I didn’t pick him. I was on a morphine drip when all of this was decided,” says Mr. Eckert, who is working with the Nevada governor’s office for consumer health assistance to negotiate a reduced bill.

There are ways to fight back against balance billing. When you are planning a procedure in advance, ask detailed questions about the potential role of out-of-network doctors in your care. Anesthesiologists, radiologists and pathologists are often the most likely to not accept many health plans, but they’re not the only ones. If possible, you can request an in-network provider, or you can seek to work out terms in advance with the doctor and insurer.

After medical treatment, you should expect to have to pay out-of-pocket any co-payment or co-insurance fee, and any deductible that your plan requires. If you get a bill that goes beyond these, start by calling your insurer and the doctor’s office for more information, as well as your employer if your health benefits are from your workplace.

Find out if you are being balance billed by a health-care provider who is in your network and for a service covered by your plan. If so, you probably don’t have to pay. States generally prohibit such charges, which also typically violate your insurer’s contract with the doctor.

If the doctor is not in your insurer’s network, there still might be steps you can take. Some states have regulations that may protect you from balance billing in certain situations, most commonly emergencies. Check with your state’s insurance regulator.

Your insurer also may be able to help; companies’ responses to unexpected out-of-network balance bills often depend on the member’s particular benefits package and whether the care was for an emergency or not. In any case, insurers say consumers should call them before writing any checks to the doctors. “You should not pay that bill and figure you’re going to get it back in the end,” says Wendy Sherry, vice president for product development at Cigna Corp.

Filing an Appeal

She says Cigna typically tries to “protect members … when it wasn’t a voluntary use of an out-of-network provider.” Aetna Inc.

says it will “attempt to work through the situation on the member’s behalf.” UnitedHealth Group Inc.

says that if a member is billed inappropriately, it will generally negotiate with the hospital or doctor “to take the member out of the middle.”

If your insurer and the doctor can’t reach a compromise and you’re still getting billed, you can file an appeal with your insurer to try to force the health plan to pay more. You can also try to negotiate with the health-care provider.

Leanne Suter and her husband, Mark Watters, a pilot, were socked with big bills for the emergency treatment Mr. Watters got after a helicopter crash last year off the coast of Florida. With injuries including broken ribs and back and punctured lungs, Mr. Watters says he was in no shape to ask questions after the accident, when an air ambulance ferried him to a trauma center. Ms. Suter, a local television reporter in Los Angeles, later checked that the hospital accepted their insurance. It did, so she assumed its doctors would as well.

But both the air service and the trauma surgeon who later operated on Mr. Watters weren’t in the couple’s insurance network. Ms. Suter hired a firm called Healthcare Advocates Inc. and appealed the initial charges. She got the health plan to increase the amount it paid for the treatment, though this still fell well short of the bill totals. Then she convinced the air service to reduce its approximately $5,600 remaining charge to $2,200, saying she couldn’t afford any more. But so far, she says, the trauma surgeon’s office hasn’t backed down, and wants more than $16,000. “Where am I going to come up with the money?” she says.

• Email: anna.mathews@wsj.com.

Printed in The Wall Street Journal, page D1

DJ-AIG Commodity Indexes

Soybean futures have slid 6.6% from a nearly four-year high at the end of April. And they have further to fall heading into the summer.

Soybeans rallied, starting in mid-December — and July futures climbed 33.1% to their April high of $15.055 a bushel — as forecasters repeatedly cut their estimates for the harvests in drought-stricken Brazil and Argentina, the world’s second- and third-largest soybean producers, behind the U.S.

At the same time, China, the world’s largest soybean importer, keeps buying U.S. soybeans, despite high prices. The U.S. Department of Agriculture has announced new sales to China or to “unknown” buyers — which traders assume means China — throughout the last month. The USDA reinforced both themes in a monthly supply-and-demand report released Thursday, cutting forecasts of soybean output in Brazil and Argentina and raising its estimate of Chinese imports.

Those reports might give futures a bump in the near term, but pitfalls lie on the path to another new high. The oilseed will likely continue to grind down in the next two to three months.

“History has proven that $15 beans on the board is unsustainable,” says Joe Vaclavik, an analyst with brokerage Straits Financial in Chicago. “When it happens, it doesn’t last very long.”

Soybean futures closed last week down 4.9% at $14.06 a bushel for the Chicago Board of Trade July contract.

THERE ARE NEW FACTORS that are likely to start driving down soybean prices in the coming weeks. First, the soy harvest in South America is approaching completion, leaving limited room for analysts to make further cuts in output forecasts. And continued high prices will eventually take a bite out of Chinese demand. Chinese buyers will likely seek alternatives, such as using extra corn and wheat in animal feed, says Andy Shissler, a broker in Downers Grove, Ill., for Roach Ag Marketing. China could also import more frozen pork, instead of buying pricey soybeans for use as feed on its own pig farms, he said.

Also, more supplies may be on the way. Nothing motivates farmers like high prices–and many in the U.S. who were lured by strong corn prices early this year may take a second look at soybeans. Analysts expect more farmers than usual to “double-crop” their wheat fields, planting soybeans immediately after harvesting wheat in the spring. That will boost U.S. acreage, which analysts previously worried would be insufficient to meet demand.

Furthermore, a fast start so far to the U.S. soy planting season could lead to an early harvest, bringing new supplies to market ahead of schedule.

High soybean prices also produce another risk. Many speculative buyers have piled into the market. Managed funds, including hedge funds, held 238,303 long positions and only 7,975 short positions in soybean futures and options as of May 8, according to the most recent government data.

If long-positioned funds sniff problems and begin to pull out, any decline would be accentuated.

The risks just outweigh the rewards for the high-flying oilseed right now. 

OWEN FLETCHER, who is based in Chicago, covers commodities and other topics for Dow Jones Newswires.

E-mail:
editors@barrons.com

By LESLIE KWOH

Unless Goldman Sachs

executive Greg Smith is shopping a book proposal, the scathing opinion piece he wrote announcing his resignation in Wednesday’s New York Times is a lesson in how not to quit, career experts say.

The piece, titled “Why I Am Leaving Goldman Sachs,” accused the banking behemoth of fostering a toxic culture where profits come before client interests. In the piece, Mr. Smith criticized senior management and aspiring leaders for hewing primarily to the goal of making money.

The right way to quit is to “just resign and move on, and keep it quiet,” says Laura Hill, president of Careers in Motion LLC, a career-coaching firm in New York City.

Mr. Smith may have sought sympathy or catharsis, but airing grievances about superiors in a letter, whether private or public, is unlikely to amount to much, she adds. “It’s not going to change the organization,” she says.

Still, Mr. Smith’s piece dominated chatter among Wall Street workers on Wednesday and set off a social-media firestorm. Online commenters’ views ran the gamut of emotion, from disgust to wistful admiration for Mr. Smith. On one point, however, nearly all agreed: Mr. Smith is unlikely to find work in finance.

Ms. Hill concurs: “What he did generally renders you unemployable in your industry” and makes him unlikely to be seen as trustworthy by many other firms.

Mr. Smith didn’t respond to multiple requests for comment Wednesday.

However harmful Mr. Smith’s letter may be for his future prospects, crisis-management experts say the episode should spur Goldman to think deeply about how and why one employee’s discontent could fester and spill over so publicly.

Employees generally become disgruntled when they feel like they aren’t being heard by management, says Davia Temin, chief executive of Temin and Company, a New York crisis- and reputation-management firm. Frustrations can grow when employees escalate concerns to higher and higher levels and still feel ignored.

While Ms. Temin says she doesn’t have firsthand knowledge of the situation within Goldman, she notes that it’s possible that writing an op-ed may have been a last resort for Mr. Smith. “If he felt like he was being heard, it probably would not have gotten to this point,” she says.

In a statement, Goldman rebutted Mr. Smith’s account of the company’s culture. “We disagree with the views expressed, which we don’t think reflect the way we run our business,” a spokeswoman wrote. “In our view, we will only be successful if our clients are successful. This fundamental truth lies at the heart of how we conduct ourselves.”

Ms. Hill of Careers in Motion notes that while it may be difficult to lead cultural change at a company as large as Goldman, disgruntled employees should handle their frustrations by first “setting an example” for their colleagues. If they’re still dissatisfied with the response, then it may be time to leave the company—gracefully. That includes refraining from bashing an employer in later job interviews.

Someone in Mr. Smith’s position, for example, might describe their previous employer in more diplomatic terms, she says: “Over time, I felt their commitment to customers was not as strong.”