Is it Possible to Stop Surprise Medical Bills?

Did you know a multitude of organizations, employers and health insurance companies are working to stop surprise medical bills?

In this day of facing COVID-19, the last thing anyone wants to worry about is receiving unexpected medical bills in the mail after receiving much-needed treatment.

What Are Surprise Medical Bills?

Surprise medical bills occur when a patient visits a health care facility that is within the patient’s health insurance network. When the patient is seen or treatment is performed by an out-of-network member at the covered facility, the patient may receive a surprise medical bill, also known as a balance bill.

This balance bill is the difference between the out-of-network rate for the non-covered provider’s services and the amount paid by the insurance company. The patient is stuck with the resulting surprise medical bill.

Why would a patient receive treatment from an out-of-network hospital at an in-network facility? For one thing, the facility’s contract with an insurance company is separate from the contract that individual staff may have with each insurance company.

There are even groups of doctors, such as gastrointestinal specialists, who see patients in one office under one umbrella name, such as Gastro Inc., but each of those doctors has individual contracts with insurers. If a patient has ABC health insurance and Gastro Inc. is on the list of covered providers, the patient still needs to make sure any appointment is with a Gastro Inc. doctor who is on the ABC health insurance plan.

Even if a patient is certain to receive treatment by an in-network provider, certain medical care workers involved down the road may not be in-network.

In some cases, the emergency room physicians at an in-network facility may themselves be out-of-network doctors. Hospitals are allowed to use staffing agencies to fill available positions, which means the insurance alliances of the doctor providing care remains a mystery until a surprise medical bill arrives in the mail.

In other cases, a behind-the-scenes provider’s care may result in a surprise medical bill. For example, if you break your arm and are treated by an in-network provider, you still may receive a surprise medical bill several weeks later from a radiologist who wrote the report on your x-ray images because the radiologist was not in-network.

In fact, the most common surprise medical bills tend to come from lab work, medical imaging (x-rays, CT scans, MRIs, etc.) or anesthesiology, according to a report from the National Conference of State Legislatures (NCSL).

How Does Surprise Medical Bill Legislation Protect You?

Some states have enacted balance bill legislation to stop surprise medical bills from haunting consumers.

The Georgetown University Center for Health Insurance Reform (CHIR) shared reports from 2017 and 2018 with the NCSL. Researchers rated states on how well they tackled these four tasks:

1. Provide consumer financial protections to extend to emergency room and in-network hospitals
2. Ensure laws cover all kinds of health insurance options, from Health Maintenance Organizations (HMOs) to Preferred Provider Organizations (PPOs)
3. Prohibit providers from issuing balance bills and keeping consumers from being responsible for paying extra charges the insurance won’t cover
4. Create a payment standard to set the amounts the insurer will pay the provider or adopt a procedure for resolving arguments overpayments between health care providers and insurance companies.

The initial study published in June 2017 found 21 states had enacted surprise medical bills laws that provided a limited amount of protection to consumers. Just six states had passed legislation that met CHIR’s definition of comprehensive protection.

The four states of Arizona, Maine, Minnesota, and Oregon adopted inaugural surprise billing laws during their 2018 legislative sessions.

In Arizona, one patient provided a firsthand story about how the law helped her. Maggie says she woke up ill one morning, so she called her family doctor’s office to make an appointment. Her doctor and his physician’s assistants were all booked for the day, but Maggie says she was told a Dr. Jones could see her at 2 pm. She contends that she didn’t know Dr. Jones, but accepted the appointment. Maggie says she paid her $40 copay, as usual, saw Dr. Jones, and left.

Two weeks later, Maggie says she received a bill for $152 from the doctor’s office. The bill said that Dr. Jones was not in her insurance network and that she would be responsible for paying the balance bill. Maggie says she knew the Arizona legislature had passed a law that required the doctor’s office to inform her in advance that Dr. Jones was not in-network prior to receiving such care so that she would be able to make an informed decision on whether to pay the out-of-network balance due or wait to see her in-network doctor the next day.

Because Maggie had not been given the opportunity to make that decision, she called her doctor’s office and explained why she should have been given the choice because it was now state law. She says that, as a result, the doctor’s office wrote off the bill.

But would Maggie had been as easily successful without the help of a lawyer if the bill had been for out-of-network hospital care for an emergency procedure that resulted in a $150,000 surprise medical bill? Maybe not.

What is the Role of the Coalition Against Surprise Medical Billing?

The Coalition Against Surprise Medical Billing is a group of employers, health insurers and doctors asking Congress to pass legislation to stop surprise medical bills.

Among the members are The American Benefits Council, America’s Health Insurance Plans, America’s Physician Groups, The Blue Cross and Blue Shield Association and The ERISA Industry Committee.

One of the measures the coalition supports is the implementation of an arbitration process to help insurers and providers settle disputes for medical bills that are more than $750.

The coalition also wants hospitals to be required to ensure that all hospital staff, lab work and diagnostic tests performed at the facility are covered by in-network pricing.

Finally, the group supports setting an unbiased, market-based benchmark payment rate that insurance companies can use to determine how much to reimburse health care providers who are not within the health plans’ networks.

Despite bipartisan support for reducing consumer liability with surprise medical bills, none of the Congressional measures have been passed. States are continuing to lead the way with their own measures to take control of out-of-network costs.

How to Fight Surprise Medical Bills

If you are the victim of a surprise medical bill, you’re not alone. Attorneys who specialize in handling balance medical bill investigations are familiar with the laws and can help you seek the financial relief you deserve.

Join a Free Surprise Medical Bill Class Action Lawsuit Investigation

If you were hit with a surprise medical bill from an out-of-network doctor at an in-network hospital, you may be entitled to compensation.

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This article is not legal advice. It is presented 
for informational purposes only.