Handling Surprise Bills
See if Services Were Covered and In-network
If you get an unexpectedly high medical bill, there are three things to consider:
- Have I met my deductible?
Note: Until you meet your deductible, you are responsible for the full cost of your medical care.
- Does my insurance cover the services I received?
Note: Refer to your policy or EOC for covered benefits and exclusions.
- Were the providers I worked with in my network ?
Note: Refer to your preferred provider directory.
If the answer to all three questions is yes, then you should only be responsible for coinsurance and you should not be balance billed. If you were balance billed in error, ask your insurer to review the situation. If your insurer denied your claims because the care you received wasn't medically necessary, or was experimental or investigatory, you have the right to appeal the denial. Your policy or EOC will tell you how to appeal.
Know Your Protections
Texas law provides certain protections against balance billing if you cannot avoid out-of-network treatment because of:
- medical emergencies
- lack of preferred providers.
Your protections against balance billing in these situations vary depending on the type of plan you have:
- HMOs and EPOs usually must pay the claim so that you don't have to pay more than your normal in-network cost-sharing. If you get a bill from an out-of-network provider who treated you because of an emergency or inadequate network, call your health plan about the bill.
- PPOs must pay these claims based on the usual and customary and your plan's cost-sharing structure. However, the out-of-network provider can balance bill you for the amount the provider charges above the usual and customary. When you pay a balance bill resulting from emergency or inadequate network treatment, report the amount you paid to your insurer. PPOs are required to count this amount toward your in-network deductible and out-of-pocket maximum.
In some cases, you can seek mediation for balance billing. Mediation is generally available if you have a PPO plan and the amount you are balance billed is $500 or more, not including cost-sharing. The bill must be from an out-of-network hospital-based provider and be for services in an in-network hospital. If mediation is an option, your provider and insurer will use a mediator to try to agree on a lower cost. If the mediation is unsuccessful, you might be able to resolve the dispute in court.
Learn more about mediation
For more information contact:
Last updated: 08/11/2016