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Surprise! Your Insurance Doesn’t Cover That

Date: April 1, 2017      Publication: Bottom Line Health      Source:  Charles B. Inlander      Print:

Joe, a friend of mine, recently had chest pain and went to a nearby emergency room to get checked out. He was there for about 12 hours, and fortunately, nothing serious was found. About a month later, however, Joe was shocked when he received a bill from the ER doctor for $350. When he called the hospital to inquire, he was told that all their ER doctors are contracted and not part of the network. Joe then called his insurer and was told that his health plan paid the doctor the network rate but that the doctor could charge patients for the difference. Rather than fight back (see below), Joe reluctantly paid the bill.

Surprise medical bills, like Joe’s, have become increasingly common because insurers are limiting their networks and hospitals are using more contracted services—all to save money. A 2015 Consumer Reports survey found that about one-third of all privately insured patients received a surprise medical bill (when their insurers paid less than what they expected) in the previous two years. And there are only five states (New York, Illinois, Florida, Connecticut and California) that have laws prohibiting or limiting such bills. But even without laws that protect you, there are ways to reduce your chances of getting a surprise medical bill. Here’s how… 

• Know your providers. Most private health insurance plans, including Medicare Advantage plans, have a limited network of doctors, hospitals and other providers (such as physical therapists) that you must use to receive maximum coverage. Some insurers provide a reduced level of coverage if you use a provider outside the plan’s network, while others offer no coverage for out-of-network providers—unless it is an emergency or you get prior authorization from the insurer. Self-defense: Ask any doctor or hospital you might use or are referred to if your insurance is accepted. If you are expecting to be hospitalized for elective surgery, such as a knee or hip replacement, you have a right to ask the facility (start with the billing office) if all the personnel involved with your care and treatment are in network. They must provide you with the answer. Important: Surprise bills most often come from anesthesiologists, radiologists, ER doctors, pathologists and neurosurgeons—doctors you generally don’t select (or sometimes even meet) when hospitalized. Be sure to ask in advance about those specialties, in particular, at the hospital you will be using.

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• Negotiate! Even with careful prechecking, a surprise bill may still arrive. Self-defense: If you receive a surprise bill, don’t be afraid to challenge it. A good first step is to ask the provider to check the bill for accuracy. If the provider says the amount you owe is correct, you can try to negotiate a lower rate on the bill. Call your insurer’s customer-service department and ask for help. If you still suspect a potential error, your insurer can also order an audit. It never hurts to ask your primary care physician or the doctor who managed your care to intervene on your behalf, too. You may also want to file a complaint about the bill (for misbilling, for example, or for failing to inform you in advance of a service you never agreed to) with your state’s insurance department. Even in states without laws protecting you, the state insurance department may help resolve the issue. If the bill is $1,000 or more, consider using a lawyer to help negotiate with the provider. Even with the attorney’s fee, you may come out ahead!

Source: Charles B. Inlander, a consumer advocate and health-care consultant based in Fogelsville, Pennsylvania. He was the founding president of the nonprofit People’s Medical Society, a consumer advocacy organization credited with key improvements in the quality of US health care, and is the author or coauthor of more than 20 consumer-health books.