A family can plan for an emergency but life can throw a curve ball in the form of a large medical bill. Even with the best health care, most can attest to a situation where a bill comes as a surprise. Isn’t insurance supposed to prevent that?
One situation that can occur is called balance billing. It means that without any prior warning, you get hit with health care bills for treatments by out-of-network providers (or from out-of-network facilities) that are not covered by your insurance. In other words, there is still a balance owed on your medical bill after you’ve paid your deductible, coinsurance or copayment and your insurance company has covered all obligated fees.
It’s an issue that is getting legislative attention on a national level. A bipartisan group of senators introduced the Protecting Patients from Surprise Medical Bills Act in August 2018.
Anyone who has seen a medical bill knows that the amount owed could be significant. This rude shock is the result of an inability of providers to have proper authorizations in place and to offer consolidated billing statements that are clear and patient friendly. It is especially painful if you have been hit with such charges after ending up in the ER and you lack the ability to check if you’re in network!
Our firm, Frontier Health Law, was retained by a medical office to assist with such collections, and it was indeed the most eye-opening (and heartbreaking) experience when it came to realizing what is wrong with our health care system. Most patients were shocked that their surgeon would interact with them in that manner — why didn’t he or she merely ask their permission before referring to an out-of-network anesthesiologist? We had no answer to that. Making those phone calls and speaking with the patients was disconcerting.
Currently, 21 states have laws in place to protect patients from balance billing. Some states prohibit balance billing altogether, while others make insurers pay the entire charge if necessary; and then some states require both. In California, if a patient visits an in-network facility, they will be responsible only for their in-network share of the cost, even if an out-of-network provider has treated them.
Nevada Assemblyman Mike Sprinkle, D-Sparks, chairman of the Health and Human Services Committee, has requested legislation to address balance billing with the goal of eliminating it. Gov. Steve Sisolak has also stated that surprise billing is one of his health care priorities. In addition, President Donald Trump recently voiced concerns on balance billing, one of his health care priorities, “The health care system too often harms people with some unfair surprises ... medical bills and the like.”
Until these rules and regulations come into play, I recommend that patients meticulously check and double-check to be sure their facilities and all doctors involved in the procedure are within their health plan’s network.
Also, know that balance billing is generally illegal in the following circumstances: if you have Medicare and a provider who accepts Medicare assignment; if you have Medicaid and your provider has an agreement with Medicaid; and if your doctor or facility has a contract with your health plan and is billing you more than that contract allows.