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Knowing Your Rights and Protections Against Surprise Medical Bills

Often, we hear from people who have received “surprise medical bills.” This blog will help you understand how you can avoid surprise medical bills, what protections you have against balance billing, and some tips to avoid balance billing altogether.

What is Balance Billing?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a co-payment, coinsurance, and/or a deductible. You may have other costs or will need to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.

The term “out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers and facilities may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service (plus co-payments, coinsurance, and non-covered amounts). This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket maximum.

What You Need to Know Before You Go

When scheduling any type of medical service, it is best to know if a provider or facility is in-network or out-of-network, before you go to your scheduled appointment. When you first call to schedule an appointment make sure to ask, “is the provider a participating preferred provider with my plan?”. You can also find this information by contacting your plan directly or verifying the status of a provider on your plan’s website.

Surprise Billing

The term “Surprise billing” refers to an unexpected balance bill. This can happen when you cannot control who is involved in your care – for example, when you have an emergency or when you schedule a procedure at an in-network facility but are unexpectedly treated by an out-of-network provider.

Protections from Balance Billing

Emergency Services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility can bill you is your plan’s in-network cost-sharing amount (such as co-payments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written consent to the provider and give up your protections not to be balance billed for these post-stabilization services.

Certain Services at an In-Network Hospital or Ambulatory Surgical Center

When you receive services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most these providers may bill you is your plan’s in-network cost-sharing amount. This applies to medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent prior to services being rendered, and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get care from out-of-network providers, you can choose a provider or facility in your plan’s preferred network.

Additional Tips to Avoid Balance Billing

Here are some tips to consider before getting medical services:

  • Ask questions before treatment.
    • Who will be involved in your treatment?
    • What are your options for facilities?
  • Be aware of out-of-network providers.
    • Some health plans will not reimburse for use of out-of-network providers, other health plans may reimburse a portion of the cost to see an out-of-network provider.
    • The use of out-of-network providers can become expensive because they can balance bill you for the services or treatment.
    • Read your plan and understand your benefits.
  • Select an in-network Facility or Center.
    • To avoid out-of-network charges, ask whether the facility you plan to use is contracted with your insurance. Otherwise, you may be responsible for a facility charge.
    • If the facility is out-of-network, you may want to ask your doctor about having the procedure done at an in-network facility.
    • If the procedure is planned, you may want to contact your health insurance plan in writing to request preauthorization or confirmation of coverage.

If you or someone you know has been denied health insurance benefits, please call Kantor & Kantor for a free consultation at 877-740-7576 or use our online contact form. We understand, and we can help.