Navigating healthcare costs can be confusing, especially when you’re faced with unexpected medical bills. It’s crucial to understand your protections, particularly concerning surprise medical bills. This guide explains your rights when you receive emergency care or are treated by an out-of-network provider at an in-network facility, ensuring you are only responsible for your plan’s standard cost-sharing.
What is Balance Billing and Why Should You Care?
When you visit a doctor or hospital, you expect to pay your share of the costs, such as copayments, coinsurance, and deductibles. However, if you receive care from a provider or facility outside of your health plan’s network, you might encounter additional charges known as balance billing, sometimes referred to as “surprise billing.”
“Out-of-network” simply means the healthcare provider or facility hasn’t agreed on contracted rates with your health insurance plan. These out-of-network providers might bill you for the difference between what your insurance pays and their full charge. This “balance” can be significantly higher than in-network costs and may not even count towards your deductible or out-of-pocket maximum.
Surprise billing is a type of balance billing that occurs unexpectedly. This often happens in situations where you don’t have control over your care, such as during an emergency or when you visit an in-network hospital but unknowingly receive treatment from an out-of-network doctor within that facility. These surprise bills can be substantial, potentially reaching thousands of dollars depending on the services.
Your Protections Against Surprise Medical Bills
Federal law protects you from balance billing in the following situations:
Emergency Services
If you experience a medical emergency and seek treatment at an out-of-network emergency room or hospital, the most you should be billed is your health plan’s in-network cost-sharing amount (copayments, coinsurance, and deductibles). You cannot be balance billed for emergency care, even after you are stabilized.
Services at In-Network Hospitals or Surgical Centers
When you receive care at an in-network hospital or ambulatory surgical center, certain providers within these facilities might be out-of-network. In these instances, these providers are also limited to billing you only your in-network cost-sharing amount. This protection applies to services like:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Intensivist services
Providers of these services cannot balance bill you, and they cannot ask you to waive your balance billing protections.
For other types of services received at in-network facilities, out-of-network providers cannot balance bill you unless you provide written consent to waive your protections. Importantly, you cannot be asked to waive these protections in surprise billing situations. Surprise bills in this context arise when:
- An in-network doctor was unavailable at the in-network facility.
- An out-of-network doctor provided services without your knowledge.
- Unforeseen medical services were necessary during your treatment.
Referrals from Your In-Network Doctor
Surprise billing protections also extend to situations where your in-network doctor refers you to an out-of-network provider without your informed consent, including referrals for lab work or pathology services. These out-of-network providers cannot balance bill you and cannot pressure you to give up your rights against balance billing.
Remember, you are never obligated to give up your balance billing protections. You always have the option to choose in-network providers and facilities.
What Happens When Balance Billing Protections Apply?
When balance billing is prohibited, you have the following rights:
- Limited Cost Responsibility: You are only responsible for paying your in-network cost-sharing amounts (copayments, coinsurance, and deductibles).
- Direct Payment to Providers: Your health plan will directly pay any additional costs to the out-of-network providers and facilities.
- Standard Coverage Rules: Your health plan must:
- Cover emergency services without requiring prior authorization.
- Cover emergency services from out-of-network providers.
- Calculate your cost-sharing based on what they would pay an in-network provider and clearly explain this in your explanation of benefits (EOB).
- Count any payments you make for emergency services or out-of-network services towards your in-network deductible and out-of-pocket limit.
Suspect an Incorrect Bill? Take Action.
If you believe you have been wrongly balance billed, it’s important to take action. Contact your health insurance provider immediately to understand your bill and your rights. You can also reach out to your state’s Department of Insurance or your state’s Attorney General’s office for assistance and to file a complaint. Understanding your rights and seeking help when needed are vital steps in protecting yourself from unfair medical billing practices and ensuring you receive the customer service you deserve from your health plan.
