Nationwide nearly one in three Americans with private insurance received a surprise medical bill between 2014 and 2016. A surprise medical bill is an unexpected bill from an out–of–network provider or from a provider not chosen by a patient. Surprise medical billing happens when a patient goes to a hospital, emergency room or doctor’s office that their health insurer considers “in-network,” only to find out later that other doctors or departments used by the facility are not “in-network” and issue separate bills.
This can also happen in physicians’ offices if they perform tests not covered by your insurance or send lab specimens to laboratories that are not “in-network,” such as what occurred to Elizabeth Moreno, a Texas State University student who was slammed with a $17,850 bill for a urine test. As a result, the insurer can decline to pay the bill outright or only pay the in-network price for the services, and the provider then bills the patient for the balance of the full “non-insurance” charge. These charges are often significantly higher than the insurance reimbursement rate. To make matters worse, the specialists who are most likely to submit these bills, such as anesthesiologists, radiologists, and laboratories, have the highest non-insurance markup rates.
Under our current medical insurance and healthcare provider reimbursement system, you can’t completely protect yourself from surprise medical bills but you can take actions that will greatly reduce your chances of receiving such a bill.
First and foremost, understand your insurance coverage.
- If you choose a plan with a high deductible, you will receive medical bills even for in-network services until your deductible is met. So find out what you will owe from your providers up front.
- Check your insurance pharmacy formulary list to make sure your medications are on it and at what copayment levels.
- Understand when your insurance will cover ambulance rides. Ambulances are generally only covered when they are deemed medically necessary as defined by your policy. This is generally if the person is unconscious, bleeding heavily, can’t breathe, or can’t be transported safely by other means. If your situation is not a true emergency and you or someone you are with can drive safely, don’t call an ambulance.
- Another reason not to call an ambulance or 911 if they are not needed is that if you are being transported by an ambulance, they decide where to take you. This decision is made regardless of your insurance or the facility’s in-network status. So that one decision to use an ambulance may not only leave you with an uncovered ambulance bill, but might leave you with an uncovered hospital bill too.
- Find an in-network primary care physician who you see regularly, even if you are not “sick.” That way if you become sick you have somewhere to go besides an emergency room.
- Read the notices posted in your doctor’s office. They very often contain disclaimers about billing for tests and services that might not be covered by insurance plans. Those notices might be notifying you that your doctor’s office will be submitting a bill for services but that a separate entity might be submitting a “facility bill” for the actual office space and equipment used. Both entities need to be in-network and covered separately to avoid a surprise bill.
- Be an informed patient. Politely ask about any recommended tests or treatments your doctor wants to perform in office or as an outpatient. If the doctor plans to perform them in office, ask if they are covered by your insurance. If they are not, ask if they are necessary and why and about less expensive alternatives.
- Ask that you only be referred to in-network specialists and do not make a specialist appointment without confirming their in-network status with your insurer.
- Make sure that any lab specimens will be sent to an in-network lab or ask to have the tests drawn and performed at an in-network outpatient lab.
- Prior to any planned procedure or test, ask the doctor performing the procedure for a complete list of anesthesiologists, assistants, or anyone else who will be part of the medical team and will be submitting a bill. If any of these individuals are not in your network, ask the provider if they can use an in-network provider.
It is also important for you to understand your insurance coverage for sick visits to your doctor versus urgent care center visits versus emergency room visits without a hospital admission. Reserve emergency room visits for true emergencies. If your regular doctor can handle the problems, go there instead and if you are unsure about whether you need an emergency room, call your doctor first.
Before an emergency or need for hospitalization arises, identify an area hospital that you would prefer to use. Contact their billing department to determine if the emergency room physicians, radiologists and anesthesiologists participate in your insurance plan. Simply going to an emergency room that is at a hospital that takes your insurance is not enough to prevent receiving a surprise medical bill. Two thirds of emergency room physicians are independent contractors, not hospital employees. Therefore, they make their own decisions about what insurance they accept and must be in-network too. Similarly, radiology departments, laboratory services and other specialty services and departments that might assist in treating you during an emergency room visit or hospitalization are also very likely independent contractors who also must be separately included within your insurance network.