Surprise medical bills are a national issue
Even if you carefully select a healthcare provider in your insurance plan’s network, you could still end up with an unexpected bill for thousands of dollars. A study by the Health Care Cost Institute found that one in seven patients received a surprise bill even though the care was delivered at an in-network hospital.
These surprise medical bills tend to happen when one member of the care team — such as an anesthesiologist or radiologist — isn’t in your plan’s network, even if the surgeon and hospital are.
Unexpected bills from out-of-network emergency room doctors and independent labs are also common. This problem isn’t new, but it’s happening more often as insurers offer narrower provider networks.
Cost can be significant
Surprise medical bills are frequently in the $500 to $1,000 range, but sometimes they top $20,000, according to Adam Fox of the Colorado Consumer Health Initiative, a consumer advocacy group.
Consumers “may have done everything right, but they’re treated by someone who is not in their network, and it’s often a situation where they have no real control to choose who their provider is,” said Kevin Lucia of the Georgetown Center on Health Insurance Reforms and co-author of a Commonwealth Fund study about surprise medical bills.
Your insurer may pay a limited amount for the out-of-network care, and then the provider charges you the difference, a practice known as “balance billing.” Because out-of-network providers haven’t negotiated a rate with the insurer, they tend to charge a lot more than the insurer pays.
“This is really a dispute between insurance companies and providers, and consumers get stuck in the middle,” Lucia said.
Help from the states, Congress
At present, 27 states have laws offering some balance-billing protection, but only 18 prohibited providers from sending these bills, according to the latest Commonwealth Fund study from July. (Maryland offers some limited protections; no laws have been passed in Virginia or D.C. at this time.)
Colorado recently strengthened its laws. Under the previous law, providers and insurers were supposed to negotiate payments and hold consumers harmless for any additional charges, but providers continued to send balance bills to consumers.
Some people were still paying the bills “without realizing they weren’t responsible for them,” Fox said. The new law, which was signed in May, prohibits providers from sending balance bills to Colorado consumers.
Recently, lawmakers in both chambers of Congress have advanced various proposals. A lobbying war has broken out between insurers and employers on one side and hospitals and doctors on the other over how to determine payments once patients are no longer liable for out-of-network care.
“The detail and time going into this discussion [in Congress] gives us a good feeling that we could have legislation passed by the end of this year,” said Claire McAndrew of Families USA.
In the meantime, your best defense is a good offense. Before scheduling a procedure, ask your health plan and providers whether everyone involved will be covered in-network.
“Be explicit on the call, keep your notes and who you talked with,” said Ted Doolittle, state healthcare advocate for the Connecticut Office of the Healthcare Advocate.
© 2019 Kiplinger. Distributed by Tribune Content Agency, LLC. Additional information on Congress provided from AP.