A surprise no one wants: Big medical bill even with coverage

February 14, 2018 by Tom Murphy
A surprise no one wants: Big medical bill even with coverage
In this Feb. 9, 2018, file photo, a radiology technician looks at a chest X-ray of a child suffering from flu symptoms at Upson Regional Medical Center in Thomaston, Ga. A nasty flu season and fresh insurance deductibles may combine this winter to smack patients around the country with expensive medical bills. (AP Photo/David Goldman, File)

This winter's nasty flu season may smack patients with a financial side effect: surprise medical bills.

People who wind up in the emergency room or need an ambulance can be blindsided by hefty, unexpected charges. This often happens after patients visit a doctor or hospital outside their insurance network so coverage was limited. Insurance deductibles that reset every January and must be paid before coverage begins can make these invoices even more painful.

Here's a look at the issue and some tips for dealing with surprises:

COMPLICATED NETWORK

Insurers form networks of , hospitals and others and then negotiate rates with them. Doctors cannot bill outside those agreed-upon rates for in-network care.

For out-of-network care, providers can bill patients the difference or leftover balance between what the insurer paid for the care and what was charged.

On top of that, many insurers also make customers pay separate, higher deductibles for out-of-network care before they provide coverage. Then they tend to cover less of the remaining bill than they would have for in-network care.

The end result could mean a bill topping several thousand dollars, depending on the coverage and the care a patient needs.

Some plans even provide no coverage for non-emergency care outside their network. That's more common with individual coverage sold on the Affordable Care Act's insurance marketplaces.

Networks in those marketplaces also have gotten particularly narrow in recent years, which makes it easier for patients to end up with an out-of-network provider.

SOURCE OF CONFUSION

People with flu symptoms have been flocking to ERs in several states this winter, and that can lead to surprise bills, in part because patients are focused on getting help and not always researching their coverage. Even if a patient choses an in-network hospital, the doctor delivering care may be out of network.

A surprise no one wants: Big medical bill even with coverage
In this Feb. 9, 2018, file photo, a nurse hooks up an IV to a flu patient at Upson Regional Medical Center in Thomaston, Ga. A nasty flu season and fresh insurance deductibles may combine this winter to smack patients around the country with expensive medical bills. (AP Photo/David Goldman, File)

For more complicated cases, the odds of that happening increase. A doctor assisting in a surgery may be out of network, and so might the anesthesiologist. A woman may give birth with help from an in-network doctor. But the baby may wind up in , where a doctor outside the network treats it.

Ambulance rides are another case where a patient may have little control over who provides the care.

"You call 911, and the ambulance that shows up is the ambulance you take," said Erin Fuse Brown, a Georgia State law professor who researches medical billing.

WAYS TO HANDLE SURPRISES

If you're having a planned surgery or procedure, check ahead with both your insurer and the hospital or doctor to make sure they are in network. Also ask about any physicians that may assist with the procedure.

If you wind up with a surprise bill, check first for errors in what was charged or if you have been billed out of network by mistake.

Then ask if the claim can be processed again as in-network care, especially if you had no way of knowing it wasn't beforehand.

If that fails, some hospitals may be willing to negotiate discounts or put you on a payment plan.

In some markets, the law may be on your side. New York, California and several other states prevent providers from dropping surprise bills on unless the person had agreed to out-of- care ahead of time.

But there are no federal laws that govern surprise , and those state laws don't apply to some forms of insurance like the millions of people receive from large employers, said Kevin Lucia of Georgetown University.

At the very least, don't ignore a surprise medical . A hospital may report your account to a credit agency or turn it over to a debt collector who sues or tries to have your wages garnished.

"It's not going to go away," said Fuse Brown.

Explore further: Surprise insurance fees often follow medical emergencies

Related Stories

Surprise insurance fees often follow medical emergencies

February 10, 2016
Recovering from a medical procedure is always a challenge, but getting hit with unexpected insurance fees can add financial hardship to the process.

Study sheds light on 'surprise' ER billing

November 17, 2016
In an unprecedented study of 2.2 million emergency room visits across the United States, Yale researchers found that 22% of patients who went to emergency departments within their health-insurance networks were treated by ...

Insurers plot test to build better provider directories

March 22, 2016
Some health insurers are hoping to ease headaches that can flare when customers try to confirm whether a doctor is covered in a plan's network of providers.

Patients face 'surprise' medical bills from out-of-network specialists

January 17, 2017
The average anesthesiologist, emergency physician, pathologist and radiologist charge more than four times what Medicare pays for similar services, often leaving privately-insured consumers stuck with surprise medical bills ...

Three questions to help sort student health coverage choices

May 14, 2015
A key question remains for many students who've finally settled on a college destination: How will they or their parents handle health care coverage?

People surprised by costs of out-of-network care, more patient educated needed

October 26, 2012
Forty percent of people who received health care outside of their insurance network did so out of necessity, finds a new study in Health Services Research. About half of those patients did not know how much they would have ...

Recommended for you

Self-lubricating latex could boost condom use: study

October 17, 2018
A perpetually unctuous, self-lubricating latex developed by a team of scientists in Boston could boost the use of condoms, they reported Wednesday in the journal Royal Society Open Science.

How healthy will we be in 2040?

October 17, 2018
A new scientific study of forecasts and alternative scenarios for life expectancy and major causes of death in 2040 shows all countries are likely to experience at least a slight increase in lifespans. In contrast, one scenario ...

Study finds evidence of intergenerational transmission of trauma among ex-POWs from the Civil War

October 16, 2018
A trio of researchers affiliated with the National Bureau of Economic Research has found evidence that suggests men who were traumatized while POWs during the U.S. Civil War transmitted that trauma to their offspring—many ...

Father's nicotine use can cause cognitive problems in children and grandchildren

October 16, 2018
A father's exposure to nicotine may cause cognitive deficits in his children and even grandchildren, according to a study in mice publishing on October 16 in the open-access journal PLOS Biology by Pradeep Bhide of Florida ...

Many supplements contain unapproved, dangerous ingredients: study

October 13, 2018
(HealthDay)—U.S. health officials have issued more than 700 warnings during the last decade about the sale of dietary supplements that contain unapproved and potentially dangerous drug ingredients, new research reveals.

Age at which women experience their first period is linked to their sons' age at puberty

October 12, 2018
The age at which young women experience their first menstrual bleeding is linked to the age at which their sons start puberty, according to the largest study to investigate this association in both sons and daughters.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.