Our Take on Healthcare News
Protecting Yourself from “Surprise” (Balance) Medical/Hospital/E.D. Bills
What is Balance Billing? Two Major Instances
Instance #1 When you receive medical services from a doctor, emergency department or medical facility that your insurance company does not have a contract with (the services are “out-of-network” O.O.N).
Example A middle-aged man became unconscious after falling at a climbing gym, and was taken to an out-of-network E.D. and hospital. He was later billed $42,000. After two years of aggravation, his insurance finally agreed to pay $9,000. He was legally responsible for $33,000.
Instance #2 Your doctor (health provider) is “in-network” with your insurance company and he/she has previously agreed on a negotiated “approved” amount for a particular service.
Example Your in-network doctor sent your insurance company a bill for $200 for an initial complete medical examination. The approved fee was $160; insurance paid 80% of the $160 = $128; patient paid 20% of $160 = $32 = $160. Patient received a “surprise” bill for $40, which was not legal.
As of 2017, only 21 states had some kind of protection laws against illegal balance billing, and only six of these states had “strong laws”. https://www.commonwealthfund.org/publications/issue-briefs/2017/jun/balance-billing-health-care-providers-assessing-consumer. A recent newspaper article reported that each year 30% of adults with private insurance fall victim to “surprise” bills.
How to Protect Yourself from Surprise Bills from O.O.N. Doctors/Medical/Rehab Facilities
- Periodically (once or twice yearly) call your doctor, nearby emergency department, hospital, rehab facility to ascertain that they continue to have contracts (are in-network) with your insurer. Don’t depend on information from the facility’s or doctor’s website which is often out of date!
- If you are considering changing to a different insurer (or if your employer is making a change), then follow #1 above. Find out if your doctor and medical facilities are in-network with your new insurer.
- Consider starting (or continue to fund) a flexible health savings plan and, if you’re eligible for a health savings account for legal “surprise” bills.
- If you can’t negotiate a fair settlement with your doctor/medical facility, try to get help from your state’s insurance department and/or an attorney specializing in health law.
- Tell your family, and also post a large note on your refrigerator or near your front door what E.D. and hospital you want to be taken to in case of a medical emergency. Have your living will, power of attorney readily available to bring to the E.D. (if you haven’t given them copies previously).
Protection from Instance #2
- Give your doctor/health provider the benefit of a questionable “balance due” by calling the billing manager. It may be a simple billing error with a simple solution.
Dr. Lazarus’ and Dr. Foster’s forthcoming book, Insider’s Guide to Quality, Affordable Healthcare will be published in March 2019. Chapter Two deals with simple-to-implement strategies for reducing out-of-pocket expenses for medical/hospital services and medications. Please visit our website www.qualityaffordablehealthcare.net for our monthly medical forum, our take on breaking healthcare news, and to ask us questions. We’ll post and/or email you our answers. Please suggest that your friends/family members sign up for our website to receive the above.
For March’s healthcare forum, we will discuss why our forthcoming book would be a valuable addition to your bookshelves. Chapters of our book will be continuously updated and integrated with our website. Important information will remain current and relevant to you and your family’s health.
Best wishes for a healthy, rewarding and long life,
Dr. Lazarus
Dr. Foster