What is a ‘Surprise’ Medical Bill?
A surprise medical bill is a receipt of much higher medical copay than the payer expects. For example, an average emergency visit costs $600, however, some surprise bills can charge upward of thousands of dollars.
This can occur due to one of several reasons, including but not limited to:
- Using an out-of-network service by accident or in an emergency
- Errors in coding and billing
How to Avoid Surprise Medical Bills
Overall, two-thirds of American adults are concerned about being unable to afford surprise medical bills. 1 in 5 insured Americans have received a surprise medical bill in the past two years. If you are one of them, you can follow these medical billing tips to avoid surprise medical bills in the future.
- Check Billing Codes with Your Insurance Provider
Before any preventative care visit, call your insurance company to find out exactly which procedures are covered under your insurance plan and their billing codes. Each procedure is assigned a six-digit billing code that determines the cost of the procedure. On the day of your visit, confirm with your physician which procedures will be performed and cross-check their billing codes.
Many insurance plans cover basic procedures like a cardiac stress test (code: 93015) or a mammogram (77067), but more advanced procedures like 3D mammography (77061/2) result in out-of-pocket medical charges.
- Stay In-Network
Every insurance company has a network of healthcare providers that agree to charge the insured medical customers a discounted rate. This list of providers consists of hospitals, doctors, dentists, lab facilities, pharmacies, etc.
Out-of-network services can cost you heftily and result in a surprise medical bill. For example, an out-of-network anesthesiologist may assist in your surgery; in this case, your insurance will not cover the claim. Instead, you will receive a much higher bill than expected since you will have to cover the cost out of your pocket.
A Kaiser Family Foundation study shows that 70% of individuals receiving surprise medical bills were unaware of the out-of-network care they received. Therefore, if you want to avoid surprise medical bills, it is crucial to make sure that you are obtaining in-network healthcare.
For health tests, let your doctor know that you would like to stay in-network. Many insurance companies can help you find in-network health services such as blood labs, MRI and radiology centers, and urgent care facilities over the phone or online.
- Research Cost Estimates in Your Locality
You may assume that all healthcare services have a uniform rate in an area. However, simple tests like an MRI can range from anywhere between $300 to $6000, even in the same locale, depending on the facility fee charges at the institute.
Most health insurance providers have pricing tools that can help you evaluate a rough estimate for the cost of your medical procedure. Start by contacting your insurance provider to gauge the possible cost of service. Next, you should contact multiple in-network healthcare providers to compare the available range of prices for the service.
Many third-party applications on the internet can also help you in comparing the charges between multiple healthcare providers in your ZIP code. With this information, you may then choose the most economically feasible health care institute.
- Beware of Balance-Billing
In emergency cases, patients may sometimes be billed for out-of-network services while receiving treatment at an in-network hospital or facility. Your health insurance may not cover the entire out-of-network cost which leaves you owing the difference between the billed cost and the amount your health insurance paid. This is called ‘balance-billing’ and can result in surprise medical bills. For example, the radiologist catering to your emergency needs may not be covered by your insurance plan.
Once the treatment is completed, little can be done to reverse the bill. To avoid surprise medical bills in emergencies, you need to be cautious before agreeing to treatments. If possible, ask your doctor for in-network alternatives
Laws are in place to protect patients from balance billing. Some states have outright banned the practice while others have legislated more transparency with billing and dispute resolution procedures. In some states, like Massachusetts, you are legally completely protected from surprise medical bills. Thus, staying informed on your state law regarding emergency care would prove beneficial when reviewing a medical bill.
- Be Prepared for Emergencies
If you face a health emergency, it is most likely that you would receive care at the nearest healthcare facility in the area, regardless of insurance coverage. Thus, surprise medical bills are quite common in cases of emergency. To avoid hefty bills, it is best to research the emergency healthcare options near you.
Find an in-network emergency room for situations where you have the option to choose. Additionally, you should explore the ambulance service options around you, too. Ambulance charges are notably high, so find an in-network service that operates in your area. Ambulance services may also be required when transferring between hospitals. If you find yourself in that predicament, you can request your healthcare providers for an in-network transport service.
- Review The Bill and Negotiate, Or File an Appeal
Billing mistakes are a common occurrence due to the sheer volume of information the billing department must manage. Medical bills contain as much as a 30% error rate, according to Medical Bill 911. Incorrect billing codes or wrong insurance records might be included in your bill, or you may be billed for procedures you have not received.
To prevent yourself from being overcharged, you should:
- Ask for an itemized bill if you have not received one
- Cross-check the itemized bills with your records for any discrepancies in the details of patient care
- Contact your healthcare provider if you have any questions about the bill
- Review the explanation of benefits to ensure your provider has paid their share
If you were unable to avoid an out-of-network service and have duly been billed for it, you may be able to negotiate your share of the payment with your insurance or healthcare provider. Most providers also offer financial aid and payment plans at low-interest rates to help you pay your bills timely without being sent to collections. Non-profit hospitals are bound by duty to provide payment plans to eligible customers in need.
If there is an error in your bill or denial of claims, you can file an appeal with your insurance company to resolve the problem. It is better to inform your healthcare provider about the concern to prevent your bill from going into collections.
- Seek the law’s aid
Currently, more than half of all American states offer some sort of legal protection from surprise medical bills, however, these laws vary dramatically. There are no consumer protection laws in most Southern states. Only patients with insurance coverage through Medicare, Medicaid, or Veterans Affairs Health Care are safe from surprise medical bills in these 17 states.
With the No Surprises Act in effect since January 2022, Congress requires states to enforce empathetic policy changes to protect individuals from insurers and healthcare providers. Notably, the Act also offers protection from surprise medical bills arising from air-ambulance usage. Further, the state law then protects individuals from expensive on-ground ambulance bills.
See Also: Hospital Billing Process Explained
If you receive a surprise medical bill, it is not recommended to remunerate the charges immediately since you may have received an inaccurate bill. Reviewing the bill for out-of-network charges, emergency services, and errors may reduce the owed amount.
When part of your treatment is not covered by your insurance plan, you may even negotiate the bill or receive financial aid. By following the medical billing tips discussed above, you can effectively avoid surprise medical bills.
Precision Hub is a top medical billing company in America, offering data-powered solutions to all your billing needs. If you found these medical billing tips helpful, check our blog section for more articles regarding healthcare and medical administration.