When it comes to surprises, an unexpected medical bill that isn't covered by your insurance is one of the worst kind. But that's the experience of 57 percent of patients. And these uncovered medical bills are so costly that they are the reason for two-thirds of bankruptcies in America today, according to the Kaiser Family Foundation.
Where Surprise Billing Happens
You are most likely to receive a surprise medical bill if you are admitted to an ER, check into a hospital for treatment, or seek care at a freestanding Urgent Care. And that's true even though you may have verified ahead of time that the facility is covered by your insurance. The problem happens when an out-of-network provider - such as an anesthesiologist, radiologist or some other specialist - treats you.
Only afterwards will you discover that these providers were out-of-network, when your insurance company refuses to pay any or all of their bill. Instead, you're on the hook for something called "balance billing." And the rates can be exorbitant, often many times greater than an insurance company would have paid, even for the simplest of procedures and care.
Congress has been trying to come up with a solution to these surprise medical billings. One piece of legislation would subject these bills to "benchmarking," a process that requires insurers to pay out-of-network providers the median in-network negotiated rate for that service based on what's common in your community.
Of course, that approach will dramatically reduce the profits of those providers now largely responsible for generating these surprise bills, usually big private-equity firms. It hasn't been in their interest to negotiate a reduced fee with insurance carriers. Instead, by remaining outside the system as out-of-network providers they're able to charge however much they want. That's why they are so opposed to the benchmarking approach to solving the surprise medical billing crisis.
Instead, they are pushing an alternative legislative approach Congress is considering, called "Independent Dispute Resolution," which requires patient and provider to submit competing proposals to an independent arbitrator.
There's a lot of money at stake in this medical care debate, which explains why many of us throughout the country are being subjected to dramatic television ads portending rampant closures of hospitals, doctor shortages, even drastic cuts to Medicare and Medicaid if either of these proposed legislative solutions passes into law.
Unless and until Congress acts, it's incumbent on us to protect ourselves. So consider these tips:
Mistakes happen all the time, with errors occurring in about eight out of 10 hospital bills. So check them over carefully. If charges seem too high, ask to have each service itemized.
If you've confirmed that a medical charge is subject to "balance billing" and is your responsibility, try negotiating a lower fee. It will help your case if you can cite the in-network cost for the care provided. Ask the provider if they're willing to accept this rate.
If you strike out in negotiations, you might be able to appeal the bill with your insurance provider. But in the meantime, to keep the bill from being sent to collections, make sure you reach out to the care provider to let him or her know you're disputing it.
If you're ultimately unsuccessful in negotiating a bill down to a manageable level, ask for a payment plan that you can afford.