In February 2020, Steve Morrow took his wife Kris for eye surgery for a degenerative eye disease called keratoconus.
They weren’t sure how much the procedure would cost – Kris’ doctor said it would depend on how bad her eye was and how laborious the procedure would be. But since it was done in the doctor’s office, they were only responsible for a $ 50 co-payment. Your PPO insurance plan would cover the rest.
“We paid an extra cost for the procedure and thought we were done,” says Morrow, who runs the Paddle About kayak website in Gilbert, AZ. “Three months later, we received an invoice for US $ 3,550 from the provider.”
It didn’t stop. Even after several phone calls to your insurance company and the provider, the bills kept coming back.
Surprise billing is common
The Morrows aren’t alone when it comes to surprise bills – when you get a medical bill that is much higher than you expected.
“Surprising medical bills have hit an all-time high,” said Gail Trauco, an oncology nurse and patient advocate who founded Medical Bill 911 to help people cope with these unexpected charges.
Around 20% of hospital bills are surprisingly charged, even for those with full insurance. There are millions of surprise bills every year, according to the Kaiser Family Foundation.
The costs add up. If your plan doesn’t cover off-grid care, your insurance company may refuse coverage entirely. Or, you may be responsible for paying the difference between what you are insured and what you are billed for (a practice known as balance sheet accounting). You can owe hundreds or thousands of dollars.
What causes a surprise billing?
A surprising billing occurs because part of your treatment was not covered by your insurance.
It is common in emergencies. An ambulance could take you to a hospital outside the network where your care is not fully covered. Or, you may need things that aren’t fully covered, like an ambulance, an air ambulance, or emergency surgery.
You can also get surprise bills if it’s not an emergency. Even if you go to a hospital or network facility, you may be billed for providers that you cannot choose, such as anesthesiologists, radiologists, and pathologists.
“Many providers may not be on the network, which leads to astronomical billing fees,” says Trauco. You may also be billed for unplanned imaging, laboratory work, or surgery.
Billing inaccuracies and errors are another source of surprise bills. “The medical bills contain an error rate of up to 30%,” she says.
That’s what happened to the Morrows. Even though their insurance company covered the eye surgery, the provider continued to incorrectly bill them. “It was a mess,” says Morrow. “But after several phone calls with the provider and the insurance company, we got everything right.”
What you can do
“You should never pay a large medical bill or a medical bill when it first arrives in your mailbox,” says Trauco. If you’re looking at an invoice and it doesn’t look quite right, the number you see might be an error.
Before paying a questionable medical bill, do some research on the facts. Ask your doctor for a copy of your medical record with detailed fees.
Make sure the records include:
- Billing codes
- Consultations
- medication
- Procedure
- Operations
When you receive your records, says Trauco, go over them in detail and ask yourself these questions:
- Is the admission and discharge diagnosis correct?
- Is the recording date correct?
- Are operations correct?
- Have I been given any medication?
You may find errors and fees to challenge. Many bills include duplicate fees or charges for things you didn’t receive, such as tests, procedures, or medication.
How to negotiate
Just because you receive an invoice doesn’t mean you are responsible for payment in full. “All medical bills are negotiable,” says Trauco.
Call your insurance company first. Ask about a one-time exception. You can agree to pay the bill at an internal network rate. If they say no, you can appeal.
Next, call the provider. “Tell your story and say you are in dire financial straits. Ask who to speak to and contact them by phone, ”says Trauco. “Polite persistence is a powerful tool.”
Ask your provider to reduce their fee to an in-network tariff. This can save you around 30% of the total costs. You can also apply for a “Pay Now Discount” which will lower the amount you have to pay if you pay immediately.
You can also get help from the Patient Advocate Foundation at patientadvocate.org.
Take the time to do your research and be patient while you negotiate.
A new law
Congress recently passed a new law called the No Surprises Act to protect consumers from surprise bills for unexpected care off the network. It covers most private health insurances and comes into force on January 1, 2022.
The new law will:
- Prohibit account balance accounting (difference between a provider’s fee and the amount allowed by your insurer)
- End the surprise emergency room billing off the network
- End surprise bills for ambulance
- Get your consent for any proposed procedure
- Ask insurers and providers to negotiate the payment rate instead of negotiating yourself
The new law does not apply to ground rescue services. It also doesn’t prejudice your state’s surprising billing laws.
This is how you prevent surprise bills
Since the new law won’t come into force until 2022, you’ll still need to be careful about your medical care and billing. “Be your own lawyer and do your homework. Know what you owe before you leave, ”says Trauco.
If you have a planned surgery or procedure, find out what information is covered in advance. Call the facility, even if they are on the network, and ask for a list of all the providers involved in your treatment. Make sure they include providers that you don’t choose yourself, like anesthetists or radiologists.
Next, call your insurance company. Confirm that every provider is on the network. Do not rely on the insurance company’s website. It can be out of date.
In an emergency, ask to be taken to a hospital on the network.
Comments are closed.