What to Do If You Get One
An unexpected medical bill can be a very unpleasant surprise. It is a bill for a medical service that you did not expect to receive because you thought your insurance would cover it. Surprise bills are becoming more common as our healthcare system becomes more complex and insurance companies reduce the number of providers in their network or exclude coverage for out-of-network services.
The best way to avoid surprise medical bills is to prevent them. It’s not always possible, but there are ways to minimize the risk.
When It Gets Tricky
One of the most common ways that people get hit with surprise bills is when they have surgery, for example, performed at an in-network hospital by an in-network surgeon but others involved in the surgery, such as an anesthesiologist or radiologist, are not in-network. This happens because hospitals contract with many types of providers and they don’t all belong to the same health plan networks.
Another common way to rack up surprise bills is in an emergency. It may not be possible to ensure access to in-network services since time is of the essence in an emergency.
Other reasons you may receive a surprise bill include:
- The bill does not yet reflect payment by the insurance company. In that case, wait until it does before making payment.
- You received someone else’s bill. Verify that the charges are for services you received.
- You received a service that isn’t covered by your plan. Or, your insurance has changed its coverage and/or in-network provider list. Keep current with what your policy covers and periodically verify that your providers are still in-network.
- You were billed for something you thought was a preventive service. Let’s say regular mammograms are covered, but if additional screening is necessary to investigate suspicious findings, those tests may be covered but applied to your deductible. That can result in an out-of-pocket “surprise” expense.
Surprise bills can be due to two factors: cost-sharing and balance billing. If your health plan includes cost-sharing, you may be responsible, for example, for 20% of the allowed charges for in-network services and 40% of the allowed charges for out-of-network services. Health plans negotiate with network providers to set fees, or allowed charges, that are lower than full fees. This protects patients from being billed the difference between the negotiated fee and the full charge. Since out-of-network providers do not have the same contract with your insurer, they may bill you for that difference, which is called balance billing. Therefore, a patient cared for by out-of-network providers may be responsible for paying their anticipated cost-share portion and the balance of the bill after the insurance company has paid.
Preventing Surprise Bills
The best way to prevent surprise bills is to make a concerted effort to avoid out-of-network providers and facilities. Confirm with your insurer that your doctors are in their network. If you are planning for a medical procedure or hospitalization, tell your doctor you want only in-network providers working on your case. Ask the billing person in your doctor’s office for a list of those who could be involved in your care and run their names and the facility by your insurer. It’s best to talk with an insurance company representative, rather than rely on potentially out-of-date lists on their website. On the day of the medical service, repeat your request for in-network providers as you are prepped for the procedure.
While it’s hard to plan for emergencies, you can learn what nearby hospitals are in-network and which use in-network emergency care providers. If possible, request that you be taken to one of these facilities. However, emergency responders make the decision where to go based on availability and type of care needed. Since timeliness of care in an emergency is critical, it may not be possible to influence who cares for you and where.
If you know in advance that you will have out-of-network services, you can negotiate the fees you will pay in advance. Everything is negotiable if you are paying out-of-pocket. Insurance companies routinely pay less than full charges so providers may be very agreeable to being paid what an insurer would pay them. A Consumer Reports article suggests starting with the billing office by asking for a fair price and stating what your ability to pay is (proof of inability to pay may be required). The article also recommends persistence; you may need to ask (and ask again) for a manager who has decision-making authority.
Ask Questions Early and Often!
Asking lots of questions shows your doctor that you are an active participant in your healthcare! Make sure you understand whether care is necessary or optional. Weigh the pros and cons and consider alternatives. (Your KnovaSolutions nurse can help!)
Find out what is covered by insurance and if you will have out-of-pocket costs. Pay close attention to your health plan’s list of in-network providers and facilities when seeking care.
Fighting a Surprise Bill
If you receive a surprise medical bill, call the provider and your insurer to explain that it was unexpected and see what can be done. Be sure to ask for an itemized bill and look for procedures, medications or supplies that you didn’t receive. Ask if the provider will accept what an insurer would normally pay and waive the balance. In the case of an emergency, some states have regulations that protect patients from balance billing. If your state is without these regulations, ask the first responders or providers to document that your transport or care was medically necessary and that you had no choice in the matter. Providing this documentation to your insurer may prompt coverage. Your employer’s human resources department may also be able to intervene with the insurer on your behalf though privacy laws may limit their role. See the box (left) for more resources.
Resources for Fighting a Surprise Medical Bill
- Patient Advocate Foundation
- Consumers Union
- Fair Health
- Hire a medical billing advocate or find out if your employer offers medical billing advocate services
- File a complaint with your state’s health insurance agency
Let Us Help
Your KnovaSolutions clinician can help you prevent unexpected medical bills and strategize about how to deal with ones you receive. We’ll help in any way possible and offer an empathetic ear too! Call us at 800/355-0885, Monday – Friday, 8 am – 5 pm, Mountain Time.
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The information contained in this newsletter is for general, educational purposes. It should not be considered a replacement for consultation with your healthcare provider. If you have concerns about your health, please contact your healthcare provider.