Avoiding Surprise Bills

Balance billing – or surprise medical bills – happens when you get a bill from a doctor, hospital, or other health care provider who isn’t part of your health plan’s network. Out-of-network providers haven't agreed to treat a health plan's members at discounted rates. Therefore, their rates are higher than the rates negotiated between a health plan and its preferred providers. Even if your health plan pays for some out-of-network services, you will have to pay the difference between what your plan will pay and what the out-of-network provider charges you. This is called balance billing. Out-of-network providers can bill you for these charges; preferred providers cannot.

There are some exceptions. In an HMO or EPO, you typically won't have to pay any balance-billed charges if you received out-of-network care because of a medical emergency or if there weren't any preferred providers available to treat you. In a PPO, you may be balance billed even for emergency services, but your expenses will count toward your in-network deductible and out-of-pocket maximum. If your balance-billed charges from a hospital-based provider are more than $500, you may request mediation.

Choose Providers in Your Plan's Network

Use your plan's preferred provider directory to choose your doctors and other providers. Depending on your plan type, your insurer might not pay for care that you get from providers outside its network. Even if your plan will cover some of out-of-network costs, it will pay a higher percentage of the costs if you use a preferred provider. Most importantly, working with a preferred provider will help you avoid balance billing.

Do I Need a Referral or Prior Authorization?

Look on Page 1 of your summary of benefits and coverage. The summary will tell you whether your plan requires you to get a referral from your primary care physician before seeing a specialist. Usually, HMO plans require a referral to see a specialist - but this requirement doesn't apply to women seeking OB-GYN care. Many plans also require you to get prior authorization before receiving some services, such as surgeries or hospital stays. Review your policy or evidence of coverage to find out which services require prior authorization.

Find out Costs Beforehand

You have the right to know the estimated cost of a medical procedure before receiving it. Many health plans have online tools to help you compare providers based on price and quality. If your plan doesn't have this type of tool, there are other ways to find out the estimated cost beforehand:

Once you know the estimated cost of the service, refer to your summary of benefits and coverage (starting on Page 2) to determine how much you will owe based on your plan's cost-sharing structure.

Request In-Network Facility-Based Providers

When you're in the hospital or another health care facility, you will probably require the services of several different providers. Even if you use an in-network facility, some of the providers who treat you might be outside of your plan's network. For instance, if you have surgery, your doctor might be in your network, but the anesthesiologist or other facility-based provider might be out-of-network. Your plan might not cover all of the anesthesiologist's charges and you may be balance billed. Make sure that you know who will be treating you in a hospital, clinic, or other health care facility and whether they are all in your plan's network.

Contact your in-network health care facility ahead of time about their facility-based providers. Tell the facility the procedure you plan on having and who your insurer is. Then ask if you will have access to preferred providers at all stages of your procedure. If the facility can't ensure that all of your providers will be in your network, you might want to use a different in-network facility. If you can't find a preferred provider, talk to your insurer and understand in advance how you will be billed since no preferred provider is available.

Be aware: Facility-based providers often move from hospital to hospital, so it's important to confirm that your facility-based providers will be in-network before each hospital procedure.

Know Where to go for Urgent Care

Be prepared for urgent care needs, so you can avoid using the ER if it’s not a true emergency. Check your provider directory for urgent care centers near you, and print a copy of urgent care locations, hours and phone numbers. Being able to access this information quickly can help you determine what your options are if you need immediate attention after hours. Make sure not to confuse a free-standing ER for an urgent care center. These facilities can look very similar, but the costs are very different.

Next Section: Handling Surprise Bills

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Last updated: 05/22/2018