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What You Need to Know About Surprise Bills

This year, more than 50% of Americans will struggle to pay for medical bills, according to data from Debt.com. When it comes to important medical issues, families should be focused on getting the best care — not worrying about how to pay for it.

But the American medical system has created an unequal playing field, pitting consumers and families up against large corporate entities with far more resources. The structure of health insurance can be unclear and difficult for consumers to understand. Families deserve to know what medical care is going to cost. But all too often, Americans are caught off guard by bills that they expected would be covered by their insurance.

This is especially true for Americans with “high-deductible health plans,” (HDHP) according to Health.com. These plans can be tricky to understand and many people don’t know how they work. People may choose a high deductible health plan because it appears less expensive upfront and offers cheaper premiums. But when the full bill arrives, they may be taken aback.

With high deductible health plans, people have to pay entirely out of pocket for care until they hit a particular threshold (at least $1400 for an individual and $2,800 for a family, according to Healthcare.gov). Some may not have realized they were signing up for a high deductible plan, or their employer might have recently switched insurers.

Others are ambushed by “surprise bills” — when a patient is treated by a provider outside of their insurance network. This is particularly true for emergency care that requires trips to the ER: roughly one in five emergency room visits lead to a surprise bill, according to Vox.

What You Need to Know About Surprise Bills

This year, more than 50% of Americans will struggle to pay for medical bills, according to data from Debt.com. When it comes to important medical issues, families should be focused on getting the best care — not worrying about how to pay for it.

But the American medical system has created an unequal playing field, pitting consumers and families up against large corporate entities with far more resources. The structure of health insurance can be unclear and difficult for consumers to understand. Families deserve to know what medical care is going to cost. But all too often, Americans are caught off guard by bills that they expected would be covered by their insurance.

This is especially true for Americans with “high-deductible health plans,” (HDHP) according to Health.com. These plans can be tricky to understand and many people don’t know how they work. People may choose a high deductible health plan because it appears less expensive upfront and offers cheaper premiums. But when the full bill arrives, they may be taken aback.

With high deductible health plans, people have to pay entirely out of pocket for care until they hit a particular threshold (at least $1400 for an individual and $2,800 for a family, according to Healthcare.gov). Some may not have realized they were signing up for a high deductible plan, or their employer might have recently switched insurers.

Others are ambushed by “surprise bills” — when a patient is treated by a provider outside of their insurance network. This is particularly true for emergency care that requires trips to the ER: roughly one in five emergency room visits lead to a surprise bill, according to Vox.

Cascading effects of medical debt

Surprise bills can trigger a domino effect of financial fallout. Families may have to find new housing, go without day-to-day necessities or delay seeking other health care, according to a survey conducted by Kaiser Health News and The New York Times.

When families have no other choice, some even have to go so far as to declare bankruptcy, according to the Kaiser Health News and New York Times survey. Two-thirds of all bankruptcies in the U.S. are tied to medical expenses, according to the United States Health and Human Services.

Then there’s the emotional toll. Navigating these situations can trigger chronic stress, which is linked to a slew of other health challenges, including premature death, according to Consumer Reports. But the good news? There are concrete steps you can take to learn about surprise billing — and how to best avoid it whenever possible.

What leads to surprise bills?

A 2018 survey on health care billing conducted by NORC, a research organization at the University of Chicago, showed that 57 of people surveyed had been surprised by a bill they thought would be covered by their health plan.

This can happen because the ins and outs of different types of health plans aren’t clearly explained. If you have a high deductible health plan (HDHP), you may not realize that none of your medical care (with the exception of certain routine care) will be covered by your insurance until you hit your deductible, according to Health.com. As an example, if you go to the doctor at the beginning of the year, you might get hit with a bill you didn’t anticipate because you likely haven’t reached the threshold yet.

Then there’s “balance billing” — when your healthcare provider bills a patient for the difference between the amount that they charge, and what the insurance company agreed to pay. If your insurance company only reimburses a small amount, you’re on the hook for the rest.

People can also be caught flat-footed by “surprise medical billing,” when a patient is billed for work from an out-of-network provider. When patients need a planned surgery, they might find a surgeon and hospital system within their insurance network specifically to avoid facing a steep bill, according to Health.com. But that patient may receive treatment at some point during the procedure by an out-of-network provider, say an anesthesiologist, without being aware of it.

“Balance billing” is already forbidden in Medicare and Medicaid, according to the United States Department of Health and Human Services (HHS). New rules that took effect in January 2022 also ban this practice for Americans with insurance through employers or commercial health plans.

What the New No Surprise Medical Bills law means for you

Changing regulations could help to protect people from facing surprise bills that can devastate their finances and families. The “No Surprises Act,” a law which takes effect In January 2022, will make it illegal for providers to bill patients more than their in-network fee.

This law will apply for emergency services and some non-emergency services under the umbrellas of anesthesiology, radiology and laboratory services, among others, according to the American Hospital Association. So long as a patient gets care at an in-network facility, they can no longer be ambushed by a “surprise bill” — even if they receive treatment from an out-of-network provider. Providers also have to follow new disclosure rules to be transparent with patients about balance billing rights.

In the meantime, the Biden-Harris administration has introduced interim rules to protect people from facing surprise bills, according to HHS. These interim measures ban surprise billing for emergency services and additional care (like an assistant surgeon or specialist) at in-network facilities. They also ban out-of-network charges without advance notice, among other protections.

How to try and avoid surprise bills

America’s health insurance system can be complex, difficult to navigate and challenging to understand. These tips and strategies from Health.com and AARP.org can help you and your family minimize your chances of getting caught off guard by unexpected medical bills.

  • Go to in-network facilities. When planning for a non-emergency procedure, do your research to learn which physicians and facilities are within your insurance network in the region where you live, according to Health.com. You can do this by checking your insurance plan’s website, calling your insurer, or calling a hospital or provider directly. When a provider refers you elsewhere (for lab work, perhaps, or an X-ray) ask if that physician or facility is in your network — and request another referral, if not.
  • Ask your provider or insurer if a specific procedure is covered by your health plan. You’ll want to provide the name of your plan, group number and member ID, according to AARP. You can also locate the “Current Procedural Terminology,” known as the CPT code, for your procedure or service. This is a 5-digit code that doctors list on bills and insurance claims.
  • Get information in writing. If you call your insurance company about the cost of a procedure, ask for information in writing to have a paper trail if you later receive a bill specifying another amount.
  • Double check that bill when it arrives. Procedures may be billed under the wrong CPT code, or even billed twice by mistake. Check each line item to ensure that you’re not being charged for anything you shouldn’t have to pay (and dispute it, if so).
  • Look up whether ambulance services are included in your health plan. Transport to the emergency room is a common cause for surprise billing — and some plans don’t cover it.

Tips to navigate unexpected Covid charges

Covid testing is supposed to be free, but some Americans are still reporting surprise bills, according to The New York Times. About 2 percent of coronavirus test bills pass a portion of costs to consumers — which translates to millions of patients facing unexpected charges. These tips compiled by The New York Times may be helpful in navigating Covid charges:

  • Seek testing at public sites. States, counties, cities and towns offer public testing facilities, where receiving surprise bills is less common, according to The New York Times. If your region doesn’t have a public test site, try your primary care doctor or a federally qualified health clinic.
  • Know your rights and express them. Insurers aren’t allowed to apply co-pays or deductibles for Covid testing. If you have insurance, you should not receive a bill (unless it’s through regular school or workplace testing, which insurers don’t have to cover).
  • If you don’t have insurance, use the federal relief fund. If you’re uninsured, a testing site might try to bill you the entire cost of a Covid test. However, the Covid-19 Uninsured Program will cover these costs. Tell the provider about this fund if they try to charge you.
  • Double check those codes. If you receive a bill, check if the test was labeled as an office visit or regular laboratory testing (Covid rules don’t apply here, so insurers are allowed to charge for such visits or services). If so, reach out to your provider’s office and ask them to accurately recode the bill.

How self-pay can help

Using self-pay can help you learn about the full cost of care upfront, according to Consumer Reports. This can be especially valuable for people with high deductible health plans.

The following are some additional tips that may help, sourced from Consumer Reports and KTVB. Patients can shop around for prices, compare options and choose a provider or facility without involving insurance at all. How can you do this? When it comes to non-emergency care, look for self-pay prices ahead of time. Many times you will need to ask up front what the cash prices are if you choose to pay cash. Often, this price is lower than your contracted HDHP price.

This can help you find a discount for the service you need. Hospitals are now required to disclose prices for procedures, though some abide by this regulation more than others, according to The Washington Post (and many make this information difficult to track down). However, the penalties being imposed by the government for not being in compliance with new price transparency rules are becoming more severe.

Other pro tips: Ask your provider to list for you the different CPT codes they expect to apply to your bill. Once you have those, you can now shop for care. You can call your insurance company or check their website for prices that correspond with each code. Solv can also help you scout prices in advance. With our Clear Price Pledge, Solv is partnering with healthcare providers across the country to show self-pay prices for common services — like COVID testing, flu shots and x-rays — to help you make the best choices for you and your family.

14 Sources

Solv has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references.

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