What happens when you go to an in-network facility (hospital or emergency room) and are treated by a doctor who is not in your insurance company’s PPO network? You get a bill from a specialist like a radiologist or anesthesiologist that exceeds your insurer’s normal reimbursement – and you’re stuck with the balance. Surprise! Or, as the insurers like to say, you’ve been subject to “balance billing.”
Roughly one in six emergency room or hospital visits results in surprise billing, although the odds vary significantly depending on where you live. Such charges can be significant as the out-of-network doctor typically charges a full “list price” for services. Consumer bankruptcies have resulted because in some cases surprise billing has amounted to tens of thousands of dollars.
What can you do about surprise billing where your insurer initially refuses to cover charges incurred at an in-network facility?
The good news: depending on state law, you may have rights that limit your responsibility for surprise billing. In Illinois, the Network Adequacy and Transparency Act protects consumers from balance billing both for services at an in-network facility and for treatment at an out-of-network facility in the event of an emergency. But consumers have to follow the specified claim procedure (see here for details).
The bad news: state law does not govern the “self-insured” group medical plans typically maintained by larger employers. So, until protective legislation pending in Congress becomes law, there will be no formal restrictions on surprise billing by self-insured medical plans.
Always appeal any surprise billing by your insurance company. Even those insurance companies that are processing claims for self-funded medical plans may have a uniform surprise billing policy responsive to state law. Also, follow up any surprise billing claim appeal that is denied with your offer to pay only a reasonable fee for the services rendered – you may be able to negotiate a better deal.