Navigator Guide FAQ of the Week: Help for Consumers Navigating a Surprise Balance Bill

Over the past couple of years, surprise “balance billing” has become an increasingly widespread – and often financially devastating – problem for consumers. Balance bills are unexpected or surprise medical bills incurred for medically necessary services that should have been covered by the patient’s health insurer. These bills can occur in two circumstances: 1) when the patient receives emergency care either at an out-of-network facility or from an out-of-network physician, or 2) when the patient receives elective nonemergency care at an in-network facility but receive services during their stay from an out-of-network health care provider, such as an anesthesiologist, radiologist, hospitalist, or other physician. Since the insurer does not have a contract with the out-of-network facility or physician, it may cover only a portion – or none – of the bill. In that case, the out-of-network facility or physician may then bill the patient for the balance of the bill. These bills can be high and are often unexpected, particularly when the patient has made every effort to get his or her care at an in-network facility.

No federal law currently protects patients from receiving these surprise balance bills, but 28 states have enacted their own laws.

CHIR has recently updated its Navigator Resource Guide, a online source for hundreds of searchable frequently asked questions (FAQs) about health insurance, to help consumers with balance billing-related FAQs, such as:

How do you avoid a balance bill?

The primary step in avoiding balance bills is to ensure that you use in-network doctors and hospitals whenever possible. While it is difficult to ensure you are taken to an in-network facility in emergency situations, there are some steps you can take to protect yourself from balance bills with respect to scheduled procedures.

Before a scheduled procedure at an in-network hospital, reach out to the hospital ahead of time to ask if there is any chance you will be treated by an out-of-network provider during the procedure and request that all care be provided by in-network providers. If the hospital is unable to give you that assurance, reach out to your insurer and ask them to assure you that they will cover all services provided while you are being treated at an in-network facility. Some states require insurers to cover your care as if it is in-network if they do not have a qualified provider in-network who can deliver covered services without you needing to travel an unreasonable distance or face an unreasonable delay. Those rules may vary depending on your state’s laws or the terms of your health plan.

In cases where you are made aware ahead of time that you will have to use an out-of-network provider due to unavailability of an in-network provider, if medically safe and feasible, ask if you can reschedule your procedure for a time when an in-network provider will be available. If that is not possible, reach out to your state department of insurance to understand your rights. Be wary of signing consent forms that may waive your protections against balance billing.

What to do if you receive a balance bill?

If you have received an unexpected bill, reach out to your insurer to ask if the plan will cover the bill in full, and reach out to the out-of-network doctor or hospital in question to ask if they will accept a lesser amount from your health plan.

You should also contact your state department of insurance and ask for assistance. Even in states without laws protecting consumers against balance billing, the state department of insurance might be able to assist you in negotiating with your insurer and healthcare provider. If the balance bill is large, you may also consider contacting your local media and elected representatives. Sometimes providers will waive excessive balance bills to limit negative attention in the press or from the legislature.

To learn more about balance billing and policy proposals to protect consumers, visit https://surprisemedicalbills.chir.georgetown.edu/

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