Billing for hospital stays and other medical services has never been simple and clear for patients, and the picture has very often been made even murkier with what is known as “surprise billing” or “balance billing.” The names derive from what the happening literally is—i.e., an unexpected bill for an unexpected balance owed. The good news is that in the interest of protecting consumers, various measures have been enacted to rein in the extent of surprise billing by specifying when it can happen and when it cannot.
UCHealth, one of the larger health services networks in Colorado, has put together an information sheet explaining your rights and protections regarding surprise medical bills. You may have seen this yourself if you obtained billable services at a UCH facility, or perhaps you’ve seen something similar from another provider. Here we will summarize the key points.
When does surprise billing occur?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have to pay additional costs, perhaps even the entire bill, if you see a provider or visit a health care facility that isn’t in your health plan’s network. For example, most Medicare Advantage (MA) plans have an associated network of physicians and other providers you must use to obtain the benefits of your MA plan, including the fees negotiated by the insurer for plan participants, which are presumed to be lower than what someone would be charged who is not in the plan.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount normally charged for a service. This is called “balance billing.” I.e., you pay the balance. This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
One obvious take-away is that if you are covered by a plan that has a designated network of providers, it is best, financially speaking, to use those network providers. But there are instances when you cannot be surprise- or balance-billed by an out-of-network provider you use. We’ll cover this next.
What happens when you’re not in control of the medical professional you see?
In an emergency situation, you may be unable to control who is involved in your care. Or there may be times when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Will you be on the hook for all the costs in such scenarios? Fortunately the answer is no, in most cases.
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you should not be charged any more than your plan’s copayments, coinsurance and/or deductible. In other words, billing should be as if you had received in-network services.
If receiving emergency services from an out-of-network provider or facility, the most you should be billed for is your plan’s in-network cost-sharing amount for those things like copayments, coinsurance, and deductibles. By the way, this includes services you may get after you’re in stable condition, unless you give written consent to be balance billed for these post-stabilization services. (UCH does not explain why anyone would want to give such consent.)
Services at an in-network hospital or ambulatory surgery center with out-of-network providers
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you, and they cannot ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and give up your protections. Also note, according to UCH, you are never required to give up your protection from balance billing. You also cannot be required to receive your care out-of-network.
When balance billing isn’t allowed, you also have other protections
The Center for Medicare and Medicaid Services (CMS) states that generally speaking, your health plan must cover emergency services without requiring you to get approval for services in advance through what is known as “prior authorization.” Your plan should also show the cost-sharing that you do pay (at in-network rates) in your Explanation of Benefits. Lastly, whatever you pay for emergency services or out-of-network services should count toward your in-network deductible and out-of-pocket limit.
CMS says if you think you’ve been wrongly billed, you can contact the No Surprises Help Desk at 1-800-985-3059. Or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Are there exceptions to your billing protections?
There can be, according to CMS. Examples:
- If you have a vision- or dental-only plan, these new billing protections generally don’t apply to services these plans cover. But if you have a health plan that includes dental or vision benefits, these protections could apply to dental or vision services covered by your health plan.
- The balance billing protections generally don’t apply to ground ambulance services.
- Some health insurance coverage programs already have protections against high medical bills. You’re already protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
Can I challenge insurance denials and/or payment demands that I get?
Yes. You can contact the No Surprises Help Desk at 1-800-985-3059 to submit your challenge. Or you can submit it online at https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing.
CMS may ask you to provide supporting documentation like medical bills and your Explanation of Benefits. They’ll send a confirmation email when they receive your case to notify you of next steps and let you know if they need any additional information. To check on the status of your submission, or to see what documentation is needed, contact the No Surprises Help Desk.
What CMS says they can do:
- Review your challenge to make sure your insurance company, medical provider, or health care facility followed surprise billing rules.
- Investigate and enforce federal laws and policies under their jurisdiction.
- Try to find patterns of problems that may need further review.
- Help you understand what documentation you need to submit or what next steps you should take.
- Help answer your questions or direct you to someone who can.
What they cannot do:
- Require medical providers or health care facilities to adjust their charges.
- Act as your lawyer or give you legal advice.
- Make medical judgments or determine if further treatment is necessary.
- Determine the value of a claim, or the amount owed to you.
- Address issues they can’t legally enforce.
If you still need help with your health insurance and have a problem or question, contact your state Consumer Assistance Program. In Colorado visit https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/co. These programs help consumers experiencing problems with their health insurance or seeking to learn about health coverage options.