In February 2020, Steve Morrow took his wife, Kris, to get an eye procedure for a degenerative eye condition called keratoconus.
They weren’t sure how much the procedure would cost — Kris’s doctor said it would depend on how bad her eye was and how involved the procedure would be. But since it was done in the doctor’s office, they were only responsible for a $50 copay. Their PPO insurance plan would cover the rest.
“We paid a copay for the procedure and thought we were done,” says Morrow, who runs the kayaking website Paddle About in Gilbert, AZ. “Three months later, we got a bill for $3,550 from the provider.”
It didn’t stop there. Even after repeated phone calls to their insurance company and the provider, the bills kept coming.
Surprise Billing Is Common
The Morrows aren’t alone when it comes to surprise billing — when you get a bill for medical services that’s a lot higher than you expected it to be.
“Surprise medical bills have reached an all-time high,” says Gail Trauco, an oncology nurse and patient advocate who founded Medical Bill 911 to help people deal with these unexpected charges.
About 20% of hospital bills have surprise charges, she says, even for people who are fully insured. According to the Kaiser Family Foundation, there are millions of surprise bills every year.
The costs add up. If your plan doesn’t cover out-of-network care, your insurance company may completely deny coverage. Or you might be responsible for paying the difference between what insurance covers and what you get charged (a practice known as balance billing). You can wind up owing hundreds or thousands of dollars.
What Causes Surprise Billing
Surprise billing happens because part of your treatment wasn’t covered by your insurance plan.
It’s common in emergencies. An ambulance could take you to an out-of-network hospital, where your care isn’t fully covered. Or you might need things that aren’t fully covered, like an ambulance, life flight, or emergency surgery.
You may also get surprise bills when it isn’t an emergency. Even if you go to an in-network hospital or facility, you may be charged for providers who you don’t get to choose, like anesthesiologists, radiologists, and pathologists.
“Many providers may be out-of-network, resulting in astronomical billing charges,” Trauco says. You may also be charged for unplanned imaging, lab work, or surgery.
Billing inaccuracies and errors are another source of surprise bills. “Medical bills contain as much as a 30% error rate,” she says.
That’s what happened to the Morrows. Even though their insurance company covered the eye procedure, the provider continued to bill them incorrectly. “It was a mess,” Morrow says. “But after multiple phone calls to the provider and the insurance company, we got everything squared away.”
What You Can Do
“You should never pay a high medical bill, or any medical bill, when it first arrives in your mailbox,” Trauco says. If you look at a bill and it doesn’t look quite right, it’s possible the number you see is an error.
Before you pay a questionable medical bill, get the facts. Ask your provider for a copy of your medical records with itemized charges.
Make sure the records include:
- Billing codes
When you get your records, Trauco says, review them in detail and ask yourself these questions:
- Is the admission diagnosis and discharge diagnosis correct?
- Are the dates of admission correct?
- Are surgeries correct?
- Was I given each medication?
You may find errors and charges you can dispute. Many bills have duplicate charges or fees for things you didn’t receive, like tests, procedures, or medications.
How to Negotiate
Just because you get a bill doesn’t mean you’re responsible for paying it in full. “All medical bills are negotiable,” Trauco says.
First, call your insurance company. Ask for a one-time exception. They may agree to cover the bill at an in-network rate. If they say no, you can file an appeal.
Next, call the provider. “Tell your story and state that you have financial hardship. Ask who you need to speak with, and contact them by phone,” Trauco says. “Polite persistence is a powerful tool.”
Try asking your provider to lower their fee to an in-network rate. That may save you about 30% of the total cost. You can also ask for a “pay now discount,” which lowers the amount you have to pay if you pay right away.
You can also get help at the Patient Advocate Foundation at patientadvocate.org.
Take time to do your research, and be patient as you negotiate.
A New Law
Congress recently passed a new law called the No Surprises Act to protect consumers against surprise billing for unexpected out-of-network care. It will cover most private health plans and will take effect Jan. 1, 2022.
The new law will:
- Ban balance billing (the difference between a provider’s charge and your insurer’s allowed amount)
- End out-of-network emergency room surprise billing
- End air ambulance surprise bills
- Require your consent for planned procedures
- Require insurers and providers to negotiate the payment rate, instead of you having to do the negotiating
The new law doesn’t cover ground ambulance services. It also doesn’t pre-empt your state’s surprise billing laws.
How to Prevent Surprise Bills
Since the new law doesn’t take effect until 2022, you still need to pay close attention to your medical care and billing. “Be your own advocate and do your homework. Know what you owe before you go,” Trauco says.
If you have a scheduled surgery or procedure, get the facts about what’s covered ahead of time. Call the facility, even if it’s in-network, and ask for a list of every provider who will be involved in your care. Make sure they include providers you don’t choose yourself, like anesthesiologists or radiologists.
Next, call your insurance company. Confirm that each provider is in-network. Don’t count on the insurance company website. It may be out-of-date.
In an emergency, ask to be taken to an in-network hospital.