Surprise! This Medical Bill Isn’t Covered by Insurance!

Before your gall bladder surgery, you did everything you were supposed to. You made sure the hospital, lab and surgeon were part of your insurer’s provider network. You cleared the time off from work. You completed all the preliminary lab tests. You bought some cool new pajamas, and brought your own pillow to the hospital.

No wonder you felt sick when you received a whopping bill for anesthesia because the anesthesiologist you never even met was an out-of-network provider.

A recent story from Kaiser Health News (KHN) recounted tales from a New York investigation of patients who had been stung by surprise bills for medical services they either thought they had cleared in advance or had no idea they had incurred. Add to this the fact that insurers are shifting a greater percentage of the cost for out-of-network services to policyholders, and you have a lot of confused, righteously angry people.

Some of the bills were for treatment in an emergency room and others were scheduled medical services, often at in-network facilities. Here’s a sampling:

  • A patient had gotten approval for an in-network surgery but received a bill for $7,515 because an out-of-network surgeon assisted.
  • A patient requiring reattachment of his finger at an in-network emergency room received a bill for $83,000 bill from the out-of-network plastic surgeon who attended him.
  • A surgical patient woke up to find that at least six doctors had signed the chart. None of the names was familiar to the patient, and all had charged for the exam/consultation while the patient was sleeping. Their fees were billed at more than $7,500.

What you’re billed depends on the type of insurance you have. Health maintenance organizations (HMOs) often cover much of the cost of care, but only for in-network providers. Preferred provider organizations (PPOs) generally pay a portion of in-network services and charge policyholders a considerably larger portion for out-of-network care. Some insurers base those payments on a percentage of Medicare rates, which generally are much lower than usual and customary averages. The consumer, of course, pays the difference.

To avoid the unpleasant surprise of an unexpected or unexpectedly large medical bill, do your due diligence in advance if your treatment is not an emergency (and, depending on its nature, possibly even then). Get confirmation from your insurance provider that the people and facilities providing your care are covered under your policy, and at what percentage. Ask your insurance company representative for ways you might be able to lower your costs, and if the company has an online “cost estimator” enabling you to get ballpark figures for both in- and out-of-network care.

Visit FAIR Health, a nonprofit organization with a national database of billed medical and dental services. Consumers can estimate and plan their medical and dental expenditures from averages derived from their Zip code, and learn how much is covered by typical insurance plans.

If you receive a medical bill you feel is unfair, contact your state’s consumer affairs department; many offer designated sites for medical billing complaints and resolution.

To avoid insurance and billing errors, see our recent post by linking here.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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