Putting your health first means more than just receiving quality medical care; it also means having peace of mind about the financial aspects of treatment. Unexpected medical bills can create significant stress and hardship. This article outlines patient protections against surprise medical billing, ensuring a health-first approach to customer service in the healthcare industry.
Understanding Balance Billing and Surprise Medical Bills
Balance billing, often referred to as surprise billing, occurs when you receive a bill for the difference between what your insurance company pays and the total amount charged by an out-of-network healthcare provider. Out-of-network refers to providers and facilities that haven’t contracted with your insurance plan. This practice can lead to unexpected expenses that may not count towards your deductible or annual out-of-pocket maximum. These surprise bills can arise even when receiving care at an in-network facility if treated by an out-of-network provider. Such instances could involve emergency situations, specialist consultations, or ancillary services like lab work.
Your Rights and Protections: Health First in Action
Federal and state laws provide crucial safeguards against balance billing, prioritizing patient well-being and financial security:
Protection for Emergency Services
If you require emergency medical care from an out-of-network provider or hospital, you are protected. The most you will be responsible for is your in-network cost-sharing, including copayments, coinsurance, and deductibles. Balance billing is prohibited for emergency services, even for treatment received after your condition stabilizes.
Protection at In-Network Facilities
Even at in-network hospitals or ambulatory surgical centers, you may encounter out-of-network providers. For specific services like emergency medicine, anesthesia, pathology, radiology, laboratory services, neonatology, assistant surgeon, hospitalist, and intensivist services, these providers cannot balance bill you. They are limited to charging your in-network cost-sharing amount. For other services at these facilities, balance billing is prohibited unless you provide explicit written consent, waiving your protections. However, you cannot waive your rights in cases of surprise bills, such as when an in-network doctor was unavailable, an out-of-network doctor provided services without your knowledge, or unforeseen medical services were necessary.
Protection for Referrals from In-Network Doctors
If your in-network doctor refers you to an out-of-network provider without your consent, including for lab or pathology services, you are protected from balance billing. These providers cannot bill you more than your in-network cost-sharing and may not request you to waive your protections.
Additional Protections and Support
When balance billing is prohibited, your health plan is generally required to cover emergency services without prior authorization, cover services by out-of-network providers in emergencies, base your cost-sharing on in-network rates, and count your payments toward your in-network deductible and out-of-pocket limit.
You have the right to choose in-network care and are never obligated to waive your protections against balance billing. If you believe you’ve been wrongly billed, contact your state’s Department of Insurance or a consumer advocacy organization for assistance.
Ensuring a Health First Customer Service Experience
Protecting patients from surprise medical bills is paramount to a health-first customer service approach. By understanding your rights and the available resources, you can navigate the healthcare system with greater confidence and financial security, focusing on your well-being without the added burden of unexpected medical expenses.
