Preventing and fighting surprise medical billing: steps consumers should take

Thirty-two percent of insured individuals who had problems paying medical bills reported receiving care from an out-of-network provider that their insurance did not cover, while 69 percent of those individuals said they were not aware that the provider was not in their plan’s network when they received the care, according to a Kaiser Family Foundation (KFF) survey published in January 2016. Betsy Imholz, special projects director and a surprise medical bill expert at Consumer Reports, noted in a January 17, 2017, article that “the problem is only growing worse as our healthcare system grows more complex and more insurance companies narrow the network of doctors they contract with or shift to insurance plans that eliminate coverage for out-of-network services.”

What is a surprise medical bill?

A medical bill that an insured individual receives from an out-of-network provider when the individual is unaware that the provider is out-of–network is referred to as a “surprise medical bill.” Out-of-network providers may charge patients whatever they choose and may bill the patient for the amounts that were not paid by the patient’s health plan, referred to as a “balance bill.”

According to a March 2017 KFF report on surprise medical bills, such bills may arise from an emergency when the individual does not have the ability to select providers. Often, emergency room (ER) physicians do not participate in the same health plan networks as the hospitals where they work. In addition, the patient may not have had the ability to choose the hospital or the ambulance provider. In situations when a patient receives planned care, such as a planned surgery from an in-network provider (for example, a hospital or ambulatory surgical center), other providers involved in the surgery may not be in the same network. In many nonemergency situations, the in-network provider rather than the patient arranges for the other providers participating in the procedure or treatment. Such providers may include anesthesiologists, radiologists, pathologists, and surgical assistants.

What consumers can do

Individuals can prevent surprise medical bills by avoiding receiving services from out-of-network providers, when possible, and fight surprise medical bills after receiving them. A Center on Health Insurance Reforms (CHIR) report identified the following steps for patients to take to prevent unexpected charges:

  • Use provider directories and other plan provided information to identify in-network providers;
  • Ask providers if they are in the patient’s health plan network;
  • After receiving a balance bill, the patient should review the plan’s explanation of benefits and notices about consumers rights;
  • Before paying a balance bill, the patient should contact the health plan and the provider to find out if the plan is willing to pay the bill and/or if the provider will accept a lesser amount; and
  • Contact the state insurance department to see if there is a remedy under  state law.

Additional tips for patients were addressed in an April 6, 2017, article in Consumer Reports written by Donna Rosato. In cases of emergency care or if ambulance service is needed, Rosato recommended the individual to ask the first responders or ER doctors to provide documentation confirming that the individual had no choice and transport by ambulance was medically necessary. She noted, however, as a preventive measure, that individuals find out, before needing to go to an ER, which nearby hospitals are in-network and which ER physicians are in-network. Then, in an emergency, if possible, the individual can request to be taken to an in-network ER. In nonemergency situations, such as a planned surgery, Rosato also suggested that individuals obtain a list from the doctor’s billing staff (and hospital) of other providers that may be part of the procedure or treatments such as an anesthesiologist, radiologist, and pathologist. Then contact the insurance plan and ask if the providers identified are in-network. If the providers are out-of-network, the individual should notify the attending physician and request providers who are in-network.