It's always a smart idea to check that your hospital is in your health plan's network before you go in for a procedure, but this proactive step still may not be enough to avoid surprise medical bills.
Millions of Americans get surprised with bills from doctors who don't participate with their health plan but who practice in hospitals that do. This often happens when an assistant surgeon or anesthesiologist you didn’t even know was going to be in the room during your surgery (and who doesn’t participate with your health plan), scrubs up and joins in during your procedure.
When it’s all over, the out-of-network doctor bills you for the difference between what your insurer paid and what the doctor charges. The practice is called “balance billing.”
The Affordable Care Act requires insurers to cover out-of-network emergency services at in-network rates. But the law doesn’t stop doctors from balance billing, and it doesn’t release patients from their responsibility to pay surprise medical bills.
So what can you do? Although you don’t have complete control over whether or not you’ll get a balance bill, there are certain steps you can take to reduce the likelihood and to fix the problem once it happens, such as:
- Plan ahead. Before a planned surgery ask about the team of healthcare providers who will treat you while you’re hospitalized. It’s very difficult to control who sees you at the hospital or to know which doctors participate in your health plan. But it can’t hurt to ask that they keep non-participating providers out of your room.
- Check for mistakes. It may be that an in-network provider got recorded incorrectly as out-of-network in your insurer’s system when your claim was processed. When you get a bill, don’t pay it right away. Instead, call your health plan to discuss the bill you received and ask if you can get the charges removed if they’re incorrect. If you get health insurance at work, your employer may be able to help dispute the bill.
- Talk to your doctor. Physicians are sensitive to the financial burden patients are under these days, including those caused by surprise medical bills. It’s worth calling to ask if the doctor is willing to reduce the price of the bill. Your health plan should also be able to step in and help. In some cases, your insurer will negotiate for you with physicians to either lower or waive out-of-network charges.
- Check your state. Federal law does not protect patients from balance billing. However, about a quarter of the states do have laws in place that protect consumers from balance billing by healthcare providers that don’t participate in their health plan. Check with your state’s department of insurance to learn about the protections where you live.
- File an appeal. The law entitles you to both an internal appeal with your insurer and an external review by an independent third party. Your health plan must provide guidelines about how to go about the appeal process.
Have questions? Call 214.501.9613