- 57 percent of Americans have been hit with a bill not covered by their insurance.
- Seeing out-of-network medical professionals is the leading cause of surprise bills.
- The problem is so bad that Congress may actually take bipartisan action to fix it.
- Meantime, you can take several steps to avoid a surprise bill.
Surprise medical bills seem to getting more outrageous by the day. There's the Texas man who was billed $108,951 when he was taken to an out-of-network hospital following a heart attack. Or the Vermont skier who paid $18,442 in hospital bills after she broke her leg on the slopes. Then there's the almost $18,000 urine test from an out-of-network lab.
Surprise medical billing — when patients receive a bill not covered by insurance through no fault of their own — has affected 57 percent of American adults, according to a recent University of Chicago survey.
These unwelcome requests for payment most often come after patients are treated at hospitals and emergency rooms by physicians and other medical professionals who aren't part of their health insurance network. Four out of 10 respondents to a recent Kaiser Family Foundation poll said they had an unexpected bill from a hospital, lab or doctor in the past year.
General outrage over outsized medical charges and efforts to publicize surprise medical bills by Kaiser News, CBS and other outlets may have encouraged Congress to engage in one of its few bipartisan efforts.
Senators from both parties plan to propose legislation by the end of March to extend protections against unexpected medical bills for insured patients. These efforts may even have the support of President Donald Trump, who at a recent roundtable on health care costs said addressing unexpected medical bills would become a top priority.
U.S. government action would go a long way to solving the problem. The reason? Federal legislation would apply to both state-regulated policies such as Affordable Care Act plans and employer-sponsored self-funded health plans that are regulated by the federal government and cover a wide range of large-company employees.
Welcome as any government action may be, for now, consumers are left to their own devices to avoid becoming yet another surprise medical bill horror story. Here's what you can do now to avoid unexpected medical bills in the future.
Check and double-check your network
If you know you're headed to the hospital soon for any type of procedure, treatment or surgery, you first want to make sure the hospital is in your insurance network. More important, you also want to check with admissions or billing, and ask if all of your expected services and treatments will come from in-network providers.
It's most common to get surprise bills from an anesthesiologist, radiologist or pathologist who works at your in-network hospital but isn't part of your insurance company's network, according to research from Consumers Union. The same goes for lab and imaging work. You may get an MRI before surgery, but the hospital's imaging department may not be considered part of your insurance network.
Reviewing your case beforehand with the hospital billing department or your team of doctors can help make sure you're cared for by providers who are either in your network or agree ahead of time to take in-network compensation for their services.
An expensive trip to the ER
Emergency room visits are a major source of surprise bills. In an emergency, you're usually treated at the nearest hospital, in network or out. And typically, you're in no position to ask if each and every doctor you see is part of your network.
For ER cases that aren't dire emergencies and in which you or a loved one are cognizant — a broken bone or sprain, for example, or a child's high fever — be sure you head to a hospital that's in your network and ask if attending physicians are in your network as well. Studies show that as many as 20 percent of emergency room doctors may not be part of the network the hospital is in.
If you find yourself waking up after an ER visit to a host of nasty bills, you may need to appeal the charges (see the next item).
Get help with your appeal
In many surprise billing cases, patients end up filing a formal appeal with their insurance company to get coverage for the charge. In some cases, insurers will help with this process and negotiate a lower charge from the medical provider. In other cases, you'll have to go through several bureaucratic hoops to get the charges covered.
For help with the appeal, first turn to your physician or surgeon, who can often help document the claim you're making and why you legitimately and unwittingly went out of network.
Also check with the National Patients Advocate Foundation, a nonprofit organization that helps patients with the appeal process.
Check your state's regulation
You may also find support from your state insurance regulators. At last count, 21 states had some sort of laws protecting consumers from surprise medical bills if they're covered under a state-regulated insurance policy. The protections vary from state to state, but in some cases the amount you must pay out of pocket may be regulated.
To find out your state's status on surprise medical bills, contact your state insurance commissioner's office.
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