Even if you carefully select a health care provider in your insurance plan's network, you could still end up with an unexpected bill for thousands of dollars. A study by the Health Care Cost Institute found that one in seven patients received a surprise bill even though the care was delivered at an in-network hospital.
These surprise medical bills tend to happen when one member of the care team--such as an anesthesiologist or radiologist--isn't in your plan's network, even if the surgeon and hospital are. Unexpected bills from out-of-network emergency room doctors and independent labs are also common. This problem isn't new, but it's happening more often as insurers offer narrower provider networks.
Surprise medical bills are frequently in the $500 to $1,000 range, but sometimes they top $20,000, says Adam Fox of the Colorado Consumer Health Initiative, a consumer advocacy group. Consumers "may have done everything right, but they're treated by someone who is not in their network, and it's often a situation where they have no real control to choose who their provider is," says Kevin Lucia of the Georgetown Center on Health Insurance Reforms and co-author of a Commonwealth Fund study about surprise medical bills.
Your insurer may pay a limited amount for the out-of-network care, and then the provider charges you the difference, a practice known as "balance billing." Because out-of-network providers haven't negotiated a rate with the insurer, they tend to charge a lot more than the insurer pays. "This is really a dispute between insurance companies and providers, and consumers get stuck in the middle," says Lucia.
Help from the states. Many states are taking action to protect consumers from these unexpected bills, but some of the laws are more effective than others. As of December 2018, 25 states had laws offering some balance-billing protection, but only nine prohibited providers from sending these bills, according to the Commonwealth Fund study.
Colorado recently strengthened its surprise medical bill laws. Under the previous law, providers and insurers were supposed to negotiate payments and hold consumers harmless for any additional charges, but providers continued to send balance bills to consumers. Some people were still paying the bills "without realizing they weren't responsible for them," says Fox. The new law, which was signed in May, prohibits providers from sending balance bills to Colorado consumers.
But even the most comprehensive state laws don't help everyone. Employers that are self-insured--they cover claims themselves rather than paying premiums to an insurer--are governed by federal rather than state laws.
There are several proposals in Congress to protect consumers from surprise bills. "The detail and time going into this discussion gives us a good feeling that we could have legislation passed by the end of this year," says Claire McAndrew of Families USA, which has been working on this issue for 20 years.
In the meantime, your best defense is a good offense. Before scheduling a procedure, ask your health plan and providers whether everyone involved will be covered in-network. "Be explicit on the call, keep your notes and who you talked with," says Ted Doolittle, state health care advocate for the Connecticut Office of the Healthcare Advocate.