Many people think that if they have health insurance, they will be protected from incurring high health care costs when they go to the hospital or emergency room. Unfortunately, this is not always the case — particularly for those patients whose health insurance has no out-of-network coverage. According to statistics, one out of every five adults with health insurance received a surprise medical bill over the past two years, with 18% of emergency room visits resulting in one or more surprise bills.

There is no federal law in place banning surprise medical bills, leaving the issue primarily up to individual states to address — many have enacted legislation to protect patients on some level. However, it’s critical to be aware of what your insurance policy covers, as well as have an understanding of the underlying structure of the facility at which you will be treated to avoid receiving a surprise medical bill.

What is a Surprise Medical Bill?

A surprise medical bill is not categorically the same as an “unexpected” medical bill. Although receiving a large medical bill might come as a surprise, the term refers specifically to bills arising from out-of-network care you received without your consent. A medical bill may qualify as a “surprise” bill if you were treated at a hospital within your insurance network but were seen by out-of-network doctors while there, without approving them and agreeing in advance to incur the out-of-network costs.

Many insurance companies will cover part of the cost of an out-of-network bill for true emergency care. However, patients usually end up being billed for the balance directly by the provider for the remainder, potentially incurring medical costs in the thousands depending on the treatment rendered.

When Might You Get a Surprise Medical Bill?

Many people incorrectly think that they will only receive one inclusive bill from the facility when they go to the emergency room or the hospital. Weeks later, they are shocked when they receive multiple individual — and often very high — bills.

Not every doctor working at a hospital is an employee of that hospital. Therefore they are not required to accept the same insurance plans that the facility might accept. Typically, hospitals contract with out-of-network doctors who treat you in the emergency room or during a hospital stay and bill at much higher rates than what in-network contracts allow. Each out-of-network provider will send a separate bill for the medical services they rendered.

Surprise medical billing can occur under the following circumstances:

  • You were a patient at a hospital in your insurance network but were treated by doctors who were out-of-network.
  • You went to the emergency room at an in-network hospital but were seen by cardiologists, surgeons, pathologists, or other specialists who were out-of-network.
  • You were transported to the hospital by an ambulance company that didn’t have a contract with your health insurance company.

Research analyzing patients’ exposure to surprise medical bills following common elective operations shows that the average amount a patient incurred for out-of-network bills between 2012 and 2017 was $2,011. For serious illnesses or emergency procedures, the cost can be considerably higher and cause patients to have no other option than to seek bankruptcy for financial relief.

State Surprise Medical Bill Laws

Half the states have some form of surprise medical billing laws that protect patients in the event of an emergency. Depending on the state, the law may prohibit balance billing entirely, provide a dispute resolution process for balance billing issues, or have other measures in place.

Some states also require providing patients with advance notice that the doctor who will be treating them is out of their insurance network. In these states, patients cannot be held liable for surprise bills incurred if they do not receive prior notice and give express consent to be treated by the out-of-network doctor.

Often, large companies fund their own health insurance plans to employees rather than pay premiums to an insurance carrier to manage and pay those claims. These are self-funded plans. It’s important to understand that state laws do not apply to employers’ self-funded plans — these plans are covered by ERISA federal law.

How Can You Avoid Surprise Medical Bills?

Even if your state has surprise medical bill laws, it’s still important to be aware of the measures you can take to avoid incurring them.

Importantly, if you know that you’re going to require medical treatment in advance or require a specific procedure to be performed, make sure that the facility is within your insurance company’s network. It would be best to inform the facility in advance that you are only authorizing treatment by doctors contracted with your insurance plan as in-network and address any questions you may have concerning coverage with your insurance company.

Additionally, while taking an ambulance may be unavoidable in some cases, it’s best to seek other forms of transportation — except in the event of a true emergency — to limit your financial liability, since ambulances often tend to be out-of-network with most insurance plans.

How Systemedic’s Medical Bill Dispute Advocates Can Help

If you’ve received a surprise medical bill for out-of-network care, an experienced medical bill dispute advocate can help. Systemedic has been providing help with medical bills for over 30 years and knows what it takes to negotiate surprise medical bills quickly and effectively.

Offering a fee-based service for those looking to dispute their medical bills, our medical bill dispute advocates are skilled in navigating the insurance maze and will not take “no” for an answer. Contact us for a consultation.