How would you feel if you received a bill related to a recent emergency room visit, but you don’t recall who the physician was? And that the amount due on the bill was an astronomical dollar amount which your insurance plan isn’t covering? Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge.
The U.S. government and more than a dozen states have passed laws to help protect people against surprise medical billing. While insurance companies and physicians should work together when such bills arise, you need to know what to expect if such a thing happens.
First, let’s clarify surprise medical billing.
Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to an In-Network hospital or emergency room facility and receive services from a physician, anesthesiologist or specialist who is not in the insurance plan network. Essentially, you don’t have any control over who is involved in your case.
Physicians are not always employees of a hospital. The hospital itself may be a free-standing building considered In-Network by your insurance plan. The actual treatment you receive may be delivered and billed by individual physicians and specialists who work at the hospital, but are not actual employees of the hospital, and are potentially considered out-of-network.
Federal and state laws have been passed to ensure that insurance companies cover such surprise bills from out-of-network providers, that prior authorization is not required, that insurance companies pay those providers a fair price. In the end, you would not owe any more than you would if those providers were all in-network, which includes costs related to copayments, coinsurance and deductibles.
Visit the Health and Human Services website to read more about protections from surprise medical billing.
All of us may get surprised when we receive a bill from a health care provider. We expect our health insurance to cover things, but it can be fuzzy as to what we truly owe. You must continue to view your insurance plan’s explanation of benefits (EOB) statement once they process the claim to determine what you owe. If you believe you’ve been wrongly billed, contact your insurance plan.
When does the Surprise Medical Billing provision no longer apply?
Once you are discharged from the hospital, emergency room or ambulatory care facility, you are back to being a regular citizen responsible for choosing your own providers. Often, patients receive discharge orders that require them to schedule follow up visits with a surgeon or a specialist. While you can continue to see the same provider who treated you in the emergency room or hospital, it’s your responsibility to know if that provider is In-Network. If you continue to receive treatment from out-of-network physicians after you are discharged, the surprise medical billing provisions no longer apply.
Your employer or medical plan is required to provide a model notice or a written explanation of the requirements of surprise medical billing laws. These notices must be made public, such as on a public website of the plan or insurer. Contact your employer or insurer to read your plan’s specific notice.