Surprise Medical Bills and Balance Billing.... or Just Billed?

Surprise Medical Bills and Balance Billing.... or Just Billed?
| by Adria Goldman

When you go to a hospital that is In-Network it only seems natural to think that everyone you work with at the hospital is covered within the facility. However, that is not the case. Clients have even come to me where they received medically necessary care at an in-network facility only to be taken to an out-of-network sister facility within the hospital’s campus to recover from radiative procedures thinking their care would be covered. The patient was then sent a bill because the in-network hospital didn’t seek pre-approval for the transfer to an out-of-network care facility that is on their grounds.

For many patients, this leaves them with medical bills that would have either benefited from pre-approval or now require insurance appeals as they are often denied upon their first request for coverage from insurance as an out-of-network provider. Many times the hospital will have to write-off these bills as “Surprise Bills” or lower them based on the standard cost of care, if an insurance company denies the claims repeatedly and then the patient is left to advocate against the illegal practice with the biller.

While states provide protections for consumers with commercial health insurance plans, the laws against balance billing and surprise billing does not apply to self-insured employer-sponsored health plans, which cover 61% of privately insured employees, according to the Kaiser Family Foundation. Self-insured policies are regulated by the federal government, not the state.

When self-insured, companies pay medical claims themselves rather than paying premiums to an insurance carrier. They operate outside of the ACA and state regulations. Self-insurance plans are regulated by the federal government and there is no federal law that prohibits surprise medical billing in self-insured plans. The patient will be left with the bill unless the state law prohibits the hospital from trying to collect above the R&C charges.

A medical bill advocate often catches the attempts to balance bill from the hospital or the attempt to deny claims by insurance companies as Surprise Bills. Some states still allow balance billing or surprise bills. Then it becomes the duty of the patient or a medical bill advocate to negotiate to lower these bills so they match the reasonable rates paid by insurance or medicare. It is a delicate dance to lower medical bills, especially when they are denied, overcharged or wrongly charged, reach out to a medical bill advocate to know what to do.