One of the main reasons we started PlushCare was because we hated getting surprise medical bills. That's why we give you the price up front and don't ever send you a bill. When the rest of healthcare still sends confusing bills by mail, it's no wonder over 100,000 patients love using PlushCare. Still, we know you may have to see a provider outside PlushCare, like a dentist, podiatrist or gynecologist, so read on to learn some smart tips for avoiding surprise medical bills.
In addition, since the No Surprises Act came into effect on January 1st, 2022, you have protections against surprise billing. If you receive emergency care or services from out-of-network providers at an in-network facility, you are protected by law from surprise billing.
Learn About Surprise Billing
Surprise billing, also known as "balance billing," is when you receive an unexpected balance bill. This can happen when there is a large difference between what your insurance plan covers and the entire amount charged for a service. This difference is known as the balance.
Surprise billing can happen when you don't have control over the services you receive, such as when you receive emergency care or are unexpectedly treated by an out-of-network provider at an in-network facility. In most cases, you are now protected from these instances under the No Surprises Act. Read more to learn about your protections from surprise billing.
Surprise Billing is Common for Americans
Even if you do have insurance, your doctor visits may not necessarily be covered in full. Unexpected surgeries, outpatient procedures, ER visits, or even primary care visits may come with unforeseen medical bills. In fact, nearly a third of the American population has received a medical bill that they did not expect, while 20% of people have visited an in-network emergency room only to find that the bill wasn't covered because their specific doctor was out-of-network.
Now that you can be protected against these instances of surprise billing, it is important to understand your rights.
How to Avoid Surprise Billing
Here are some tips on how to deal with a surprise medical bill you may encounter in our American healthcare system:
1. Make sure you understand your insurance policy.
Your health insurance policy will dictate exactly how much you pay in medical bills, so make sure that you stay on top of it. Knowing what your deductible is, what your copay or coinsurance is, and what exactly your plan covers - before you get care - will help you prevent any unwanted bills.
Always make sure that you read any mail you receive from your insurance company and stay up to date with any policy changes that occur. This will help you manage any unexpected medical charges that may come your way and will hopefully prevent any unwanted bills.
2. Review the bill carefully for details and mistakes.
Hospitals are big organizations that handle a lot of different billing data, so it's actually quite common for them to make a mistake. You may have been billed for a service or procedure you didn't receive, your bill may have the wrong date, or the provider might have mistaken your insurance information.
Even if all of this information is correct, the charges for specific items may seem unusually high. This might mean that there were adjustments to your insurance policy or that the insurance doesn't cover the specific brand of treatment that you received. Always make sure that you read mail from your insurance company and stay up to date with policy changes so that you can prevent unwanted medical charges.
When reviewing the details of your medical bill, check if you were billed for emergency services, or if you were billed for out-of-network services at an in-network care facility. In these cases, under the No Surprises Act, the most you can be billed for is your insurance plan's in-network cost sharing amount, such as your copay or coinsurance.
3. Get in touch with your care providers or your state's Insurance Department.
When you receive a surprise medical bill, it's crucial that you get in touch with your insurer, doctor, and hospital (or other medical organization) as quickly as possible.
If you've been wrongly billed or have questions about your protections against surprise billing, you can contact the No Surprises Help Desk for free, or contact your state's Insurance Department, which you can find at NAIC.
When speaking with your insurance company, ask for detailed information on each itemized charge on your bill. Make sure you clarify each of the following:
Deductible: Your deductible is the amount that you are required to pay for your medical services before your insurance will cover anything. If you have a high-deductible plan, it is possible that your insurance may not cover the services you received. Be sure that you have a full understanding of your deductible to avoid any surprise charges.
Copay: Your copay is the amount that you pay to supplement your insurance coverage. For example, if an annual physical costs $250 total, your insurance might cover $225 and require that you pay a $25 copay directly to your doctor's office. Knowing what your copay is will help you decipher your medical bill and better understand any confusing charges.
Out-of-pocket maximum: Your out-of-pocket maximum is exactly what it sounds like - the maximum amount that you will pay for any medical services under your plan (usually for that given year of coverage). Knowing your out-of-pocket maximum is particularly helpful when dealing with surprise medical bills because you can clearly demonstrate where you are being overcharged.
Your insurance company representative can walk you through each of these things and help you decipher whether you should be receiving more coverage than your bill reflects. You can also ask the insurance company to speak directly with your doctor or healthcare provider to negotiate a lower rate.
Also get in touch with your healthcare provider to ask whether they are able and willing to charge the typical market or in-network rate (i.e. to charge the amount that it would cost if they were in-network with your insurance plan). Be sure to ask:
Why you were charged for each specific service
Which items on your bill are negotiable: Some providers will offer a sliding scale for services if your insurance does not cover them or you do not have insurance. Make sure to inquire whether you qualify.
Whether your diagnosis codes were billed properly for full coverage: A diagnosis code tells the insurance company what you were being treated for and directs them to cover (or not cover) each service accordingly. If your provider mis-labeled the diagnosis code, it can make all of the difference. Make sure that any preventive services are labeled as such (as those are typically covered by insurance) and clarify all other codes with your provider to be safe.
If you found out that you were billed for emergency services or for out-of-network services at an in-network health facility, you are protected under the No Surprises Act. If the providers did not correct the billing issue, contact the No Surprises Help Desk or get in touch with your state's Insurance Department to get help beginning the process of correcting the bill.
Once you are clear on all of these factors, you can try step 4.
4. File an appeal with your insurance company.
You can file a formal appeal with your insurance company to try and get them to cover more of the services billed. Medical bills typically provide instructions on how you can appeal the charges.
While you're going through the appeal process, notify your doctor's office so they know that you are disputing the bill. Ask them to avoid sending the bill to collections while you get it covered, but understand that doctors are not obligated to hold off on sending the bill to collections if it's been too long.
The current healthcare system is confusing enough as it is, never mind surprise bills and charges. If you do wind up with an unexpected charge, you have certain protections, and there are certainly ways to appeal it. Also know that if you are not successful in appealing a valid medical bill, you can always look into payment plans and/or financial aid.
Read More About Health Insurance:
PlushCare is dedicated to providing you with accurate and trustworthy health information.
CMS.gov. No Surprises: Understand your rights against surprise medical bills. Accessed on August 23, 2022 at https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills.