The high cost of medical care is giving some Americans sticker shock. Annual health care spending in the U.S. is estimated to be $3.5 trillion.
Hospital costs make up almost a third of that total.
And a portion of those costs come as a big surprise.
Whether intentional or due to careless mistakes, “surprise” medical charges are common.
A surprise medical bill happens when you get a bill from a doctor, hospital, or other healthcare provider who isn’t part of your health plan’s network. Often, consumers don’t know they were getting care from out-of-network providers.
“Particularly if you are a Medicare recipient, you need to be extra careful about what you are being billed. Often people are being billed for unnecessary medical services, or the first party payer has been changed by the consumer during an enrollment period in the later part or early part of winter, later part of November, December, they start talking about enrollment and change their insurance or their employer changes their insurance,” said Attorney Joe Flores.
Knowing what to do before, and potentially after, a surprise medical bill arrives in your mailbox can make a big difference in your bank account.
“The explanation of benefits or EOB that you receive on your billing statement is most important. You need to find out what has been paid and what has not. And if you don’t have someone that knows about medical billing, there are services out there that can help. There are professional billers, there are health law lawyers, and just the billing department at the hospital itself,” said Flores.
If you believe you’ve been treated unfairly, file a complaint with the agency that regulates your provider or health plan.
“4 out of 5 people will not complain, and 4 out of 5 bills are flawed. And we need to make sure we check what benefits are covered, what are exclusions to the policy, and we need to make sure we have all that squared away,” said Flores.
This situation is not uncommon, especially for senior citizens and veterans.
“If you have a cognitive deficit or you can’t read correctly with your eyes being affected or cognitive deficit, have one of your love ones or someone with an area agency on aging or someone that has health care knowledge, view it. And please go to the hospital billing department first, and if that doesn’t help, seek relief with your state or federal authorities,” said Flores.
Texas law allows many consumers, depending on their insurance provider, to seek mediation for balanced bills that exceed $500.
The program is run by the Texas Department of Insurance.
If you do actually owe the bill, you can also try to negotiate with the provider yourself. They may offer a payment plan or discount if you agree to pay in cash immediately.
How can I protect myself from a surprise bill?
- For planned procedures, find out in advance whether your providers are contracted with your health plan. This is especially important in the case of facility-based providers, such as radiologists, anesthesiologists, pathologists, and neonatologists. Even if a hospital is in your health plan’s network, some doctors who provide services there might not be.
- Call your health plan to make sure the services you will get are covered under your policy. If the services are not covered, you will have to pay the charges.
- Texas law gives patients the right to request estimates of charges. Doctors and other providers and health plans have 10 days to give you the estimates, so you won’t be able to get them in cases of emergencies. Some providers and health plans also have cost information on their websites.
- Shop around. Use the The Texas Department of Insurance’s Healthcare Costs website to find average costs for common medical procedures in your area. Websites – such as NewChoicehealth.com, FairHealthConsumer.org, and TxPricePoint.org – also can help you estimate the prices of various procedures.
- If there aren’t any contracted providers available, your health plan might be able to work out a discounted payment. You also might be able to ask your doctor or provider if they’ll accept payment options in advance. In some cases, the health plan may be required to make sure you aren’t balance billed.