I’ve heard the term “surprise billing” in the news recently and I’m concerned about how it could affect my family, especially if we have to go to the emergency room for a bleed and a provider is out-of-network. Can you share more on this issue and what we can do if it happens to us?
Tired of Surprises
Great question! The term “surprise billing” (or “balance billing”, as it’s also known) describes a situation where a health care provider bills you for an amount over and above (a) what your insurer is obligated to pay and (b) what you owe for your deductible/coinsurance/copayment. Typically, the problem arises when either a provider or a portion of the service is out-of-network under your health insurance. If the service isn’t covered by your plan, or the provider doesn’t participate in your insurer’s network, that means the plan’s negotiated rates don’t apply and the provider can charge whatever they want. The insurer will pay only a percentage of that amount (what the insurer deems to be “reasonable and customary”), and the provider is then free to bill you for the entire remaining balance.
Balance billing problems occur especially often with respect to emergency room visits: even if you go to an in-network hospital, it may turn out that the treating provider is out-of-network. When you are faced with an emergency, you don’t always have the time or awareness to know whether or not the provider will be covered by your insurance, making this a particularly challenging situation. Sarah Kliff, health policy reporter for Vox News, has been collecting stories about surprise billing and shares one especially eye-opening account of a patient’s experience after a bike accident landed her in the emergency room in this recent article.
Unfortunately, it is hard to protect yourself against balance billing. Medicare has financial protections in place, as do some states (you can find a list of states in The Commonwealth Fund’s issue brief). Â But those laws don’t protect you if you are insured through a self-funded employer plan. Congress may take up legislation addressing surprise bills in the coming months; HFA will continue to monitor this issue and post updates in the Washington Wire and Action Alerts.
There’s no one-size-fits-all approach to addressing this health insurance issue it if happens to you. Here are some steps you may wish to consider, as recommended by VeryWellHealth:
- Figure out whether the balance bill is allowable – or, whether the charge results from error or fraud
- If you think the bill is erroneous, contact the provider’s billing office and ask questions
- If you went to an in-network facility but nonetheless got care from an out-of-network provider, contact your state’s insurance department to see if any state laws protect you from balance billing under those circumstances
- If you received a legitimate balance bill, and no state laws offer protection, see if you can negotiate with the provider’s office (perhaps setting up a payment plan)
- Consider, too, negotiating with your insurer. You can request a reconsideration of the plan’s decision to treat the claim as out-of-network. If that fails, you may wish to follow your health plan’s complaint resolution process.
Consumer Reports gives additional helpful tips on how to protect your finances in this piece on medical billing and A Patient’s Financial Bill of Rights. Further, Elizabeth Rosenthal, M.D., author of “An American Sickness”, suggests that if you’re admitted to the hospital and asked to sign a document accepting financial responsibility, write in that you consent only if your care is in network. This will at least give you a basis for disputing bills later, if you are charged out-of-network fees.
Hopefully, these steps can help protect you from receiving surprise bills. If you receive an unexpected bill, however, please reach out to HFA’s Project CALLS team to report the issue. By collecting stories from patients about surprise billing and other health insurance issues, HFA can build a case for change.
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance
 Wang, P. (2018, September). 6 Ways to Fix Mistakes on Your Medical Bills. Consumer Reports Magazine, pp. 48-52