Imagine you go to a hospital for a routine procedure. You’ve made sure your hospital and doctor are covered by your insurance. The procedure goes well, and you head home to recover. Two weeks later, you get the bill, but instead of owing the copayment you expected, you get a bill for nearly $4,000. It turns out that the anesthesiologist who assisted with your procedure -- and who you did not choose -- was “out of network,” so your insurance won’t cover that bill as expected. You now owe the difference between what your insurance will pay the out-of-network anesthesiologist and what you were billed.
These types of surprise medical bills are exceedingly common. Studies have shown that roughly one in six scheduled hospital or emergency visits results in one -- and they’re expensive. An average emergency room surprise bill is around $600, and some cost tens of thousands of dollars.
Patients who have insurance coverage through Medicare orMedicaid, or who are on Veterans Affairs Health Care, are protected from surprise medical bills.
Over the past few years, most states have enacted some form of consumer protections. U.S. PIRG Education Fund has put together tip sheets that help explain some of these state policies.
However, 17 states still offer no protections at all: Alabama, Alaska, Arkansas, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Wisconsin, and Wyoming. Don’t fret: If you have private insurance and live in one of these states, you can take steps to avoid getting one of these surprise bills and to lower the cost if you do receive one.
Do your best to prevent a surprise medical bill.
Check with your insurer to make sure you are choosing a provider that is covered by your insurance. Make sure that the hospital or health care facility (lab, diagnostic center, surgery center) is in your insurance network before you get treated there.
When planning hospitalizations at an in-network facility, check with the facility to ensure that all providers (surgeons, anesthesiologists, and others), lab services (such as blood work) and imaging services (such as X-rays, MRIs) are covered by your insurance plan. Furthermore, specifically request that any additional services you may need are covered by your insurer.
Know where your nearest in-network emergency room is for those times when it is possible to choose.
Try to reduce the amount you owe.
Ask for an itemized bill and check that you are not being mistakenly billed for treatment you did not receive.
Compare the itemized bill to your Explanation of Benefits to see whether your insurer is paying its share. Sometimes patients are billed for services because their provider sent the wrong billing code to the insurer.
Contact your provider and ask about anything you don’t understand.
Contact your insurer to see if any mistakes were made on their end. Ask them to explain any charges you don’t understand.
Even if there are no mistakes, you can try to negotiate with your provider. Many hospitals have patient advocate departments to help you manage your bills.
If you have a problem with your insurance company, contact your state’s insurance department to file a complaint. If you have a complaint about your hospital’s billing, contact your state’s health department or consumer affairs office. They may be able to help you fight the bill.
Keep careful notes of all conversations you have. Get the names of the people you are speaking to. Keep your files in one place for easy access.
Be patient and clear in your requests.
Don’t delay in handling concerns and questions about your bill. You want to prevent your bills from being sent to a debt collections company while you negotiate.
Special information during the COVID-19 pandemic
Testing for COVID-19 is free for both insured and uninsured consumers. Health plans are required to cover the cost of testing (even if you don’t have symptoms or have not been exposed to someone with COVID). This means that if you want to be tested for any reason, such as before visiting a family member, your insurance must pay for the test and cannot bill you for any copay, coinsurance, or deductible.
Even though the test is free, many people have been billed for other fees, such as a “facility fee.” When you choose a testing site, call to be sure there are no additional fees the site will charge. There are sites in each state that offer testing with no additional fees. The federal government has a list of locations. To find out more about COVID testing in your state, use this resource.
All plans are required to pay for any approved COVID vaccine and any administration costs. You are not required to pay any cost-sharing (copay, coinsurance, or deductible) related to getting a vaccine against the COVID-19 virus.
Good news! New consumer protections are coming in January 2022
In a victory for consumers, Congress recently passed the No Surprises Act to expand surprise billing protections to all insured Americans beginning in January 2022. The federal law will protect patients from surprise out-of-network bills for emergency treatment and from surprise bills for non-emergency treatment at in-network hospitals. The law will also prevent air ambulances from sending out-of-network surprise bills.
Until the consumer protections from the No Surprises Act go into effect next year, it is important to try to avoid receiving out-of-network care. It is always important to understand your protections and know how to fight an unfair and unexpected bill.
Photo by Leal Marcelo on Unsplash