Your Rights & Protections Against Surprise Medical Bills

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or deductible, depending on what type of health insurance coverage you have. You may also have other costs, or have to pay the entire bill if you see approver or visit a health care facility that is not in your health plan’s network.

“Out-of-network” describes providers and facilities that have not signed a contract with your health insurance plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount they charged for a service. This is called “balance billing”. This amount of bill is likely more than in-network costs for the same service, and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care- like when you have an emergency or when you schedule a visit at an in-network facility, but are unexpectedly treated by an out-of-network provider.

When my son was sick many years ago, the hospital he was admitted to was in-network with his health plan coverage. Every physician that cared for him at that hospital was also in-network, meaning they took his health care plan coverage. One surgeon who performed surgery on him ended up being out-of-network. That meant that we received a “balance bill” for his services that was much greater than what an in-network provider would have charged. This out-of-network “balance” bill was definitely a SURPRISE bill. After several months of appealing the insurance plan’s billing for an out-of-network provider, I was able to get them to consider the surgeon as an in network provider and we had zero balance payable to the surgeon. Appeals do work but you need to be persistent. You need to keep great notes about who and when you spoke to agents of the insurance plan. You need to make copies of every text, email and letter you sent them during the appeal process. And since this process took months to achieve, I made sure to keep the surgeons billing manager informed so that they would not send my son’s bill to a collection agency. The lesson learned was to ask every health care provider you see in the hospital if they are in-network. If not, you can request one who is.

You are protected from balance billing for the following scenarios:

Emergency services: If you have a medical emergency and receive emergency services from an out-of-network provider or facility, the most the provider or facility can bill you is your plan’s in-network cost-sharing amount (such as copayments or coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are medically stabilized unless you give written consent and give up your protections from being balanced billed for these post-stabilized services. Every American citizen is guaranteed emergency care for life-threatening conditions. Every pregnant woman in laborr is entitled to received emergency care. This is irregardless of the fact that you have or do not have health insurance. Not one needs pre-authorization from your health insurance company for emergency services. Once stabilized, the patient without health insurance or who is out-of-network can expect to be transported to a different facility.

Certain services at an in-network hospital or ambulatory surgery center: When you receive services from an in-network hospital or ambulatory surgery center, certain providers there may be out-of-network. In these cases, the most providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balanced billed. If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give them written consent and give up your protections. It is important that you read EVERY document you sign in the hospital., especially any that have to do with billing. If you are unable to do so, be sure to have patient advocate with you to help understand what you are signing. During my 32 year old son’s hospitalization, I was asked to sign a form stating that I would be responsible for his hospital bills. I refused to sign it as he was past majority age of 18 and legally, I was not responsible for his debts.

You are only responsible for paying your share of the cost of care (like copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan must cover emergency services without requiring approval for services in advance (prior authorization). Your plan must cover emergency services by our-of-network providers. Their Explanation of Benefits (EOB) on their claim statements should show the care was paid for as in-network. Note that any amount you pay out-of-pocket for emergency or facility services counts towards your deductible and out-of-pocket limit.

Always asked for an itemized bill from the hospital’s billing department before leaving the hospital. They may end up having to mail it to you.

Keep in mind that when you are on straight Medicare A & B with a separate Medicare gap supplemental plan, your bills are usually covered 100%. Medicare covers 80% of all costs. The supplement picks up the remaining 20%. 98% of physicians across America are participating providers in Medicare.

Visit www.cms.gov/nosurprises for more information about your rights under federal law.

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