How to handle Surprise Medical Bills

Ever get a bill from a medical provider you were not expecting?  Do you know how to handle it?  Read on to learn some things to look out for and how to handle your surprise medical bill.

Due to Mrs. r2e’s cancer diagnosis we have only recently become big consumers of healthcare.  Before this started three years ago we had preventative visits and that was about it.  OK, there was that one time our youngest so got a hairline fracture in his fibula (leg) and we did not realize it until 4 weeks later (“walk it off son, toughin’ up” said Mr. r2e).

With my 28 years of healthcare administration experience I knew about surprise medical bills.  Though my viewpoint was not as a consumer, it was as an administrator.  I knew that we had a small number of hospital based providers (physicians) that we used but also knew they were not in all the same insurance plans the hospital was.

Hospital based providers are mainly physicians (or nurse practioners/physician assistants) that work within a hospital.  While the latest trends are for hospitals to employ physicians again, there are several specialties that are still separate.  Examples are radiologists, emergency department physicians, anesthesiologists and also some surgeons.

When Mrs. r2e was diagnosed with cancer I was still working at a hospital and had great insurance.  I knew as an administrator that all the providers, including hospital based providers, were all in-network with the insurance we had.  After I was re-organized out of a job and took a severance I changed health insurance plans to my new employer.  I carefully read the benefits package before I accepted the job to ensure Mrs. r2e’s providers were in-network – which they were.  I was a bit concerned so I not only verified on the ole’ innerweb but I also called the insurer to confirm.

Everything was fine and dandy insurance wise until Mrs. r2e had an unplanned visit to the emergency room the Friday after Thanksgiving.  Since all her regular providers were off we ended up at the E.R. due to severe side affects to her chemotherapy.  The providers and the service were fine.  I dutifully signed the “Consent to Medical Treatment and Consent for “Billing” without giving it a second though.  (Billing highlighted on purpose).

A couple weeks later I received an email notice about our Explanation of Benefits (EOB) being processed for this visit.  When I logged in to review it I was surprised to see that my insurance plan would NOT pay the ER Physician bill.  (Insurance did pay the hospital bill).  It took me a minute to understand why but in fine print below the dollars were notes about the ER Physician group NOT being in-network with my insurance.

ED Doc EOB Initial

It may be hard to see but the 1 I placed on the EOB reads, “(1) Services provided are covered up to the allowable amount. Since that amount has been paid to a non-contracting provider, no additional payment can be made. If this claim is paid under an insurance policy, complaints regarding the payment amount may be directed to the Texas Department of Insurance Consumer Protection Division at 1-800-252-3439.”  I emphasized the non-contracting provider part since that is key to this discussion.

The item I labeled with 2 also had a clue, “(A) Your Health Care Plan reduces benefits when a patient receives services from a provider that is not a member of the Participating Provider Option (PPO) network. Since you elected to receive services from a provider that is not part of this network, you are responsible for the first $11,000.00 of eligible services.”  Reference to the provider not being in-network (red).  Since this was a E.R. Visit I got a kick out of the “Since you elected” part – umm, no, please forgive me for not asking the E.R. physician seeing Mrs. r2e was in network.

The item I labeled 3 in on the EOB due to Texas Law (SB 507), enacted in 2017.  Insurers and Medical Providers are required to put wording on EOBs and Bills when Out of Network situations come up.  This disclosure sealed the deal that the ER Physician group was out-of-network.

So, what did I do?  I saved the EOB to our computer and waited.  Yep, no sense spending effort until I heard from the ER Physician Group.  After about two weeks I received a bill from the ER Physician Group telling me I owed $1,418.00.  Mighty generous of them to discount by $484 (from the gross charge of $1,902).

Then I waited again.  I know how the healthcare collections process works.  Even the most respected medical providers will refer you to a collection agency.  HOWEVER, generally they will not report it to the credit bureaus because they do not want to be on the 10 o’clock news with some really sick guy flashing up a big bill.

I finally contacted the ER Physician group about the bill.  I took meticulous notes throughout the conversation.  I explained the situation and the insurance EOB stating that the ER Physician Group was out-of-network.  To my surprise the customer representative insisted they were in-network.  I told her I had the EOB stating otherwise.  She still insisted. 

I suggested maybe that the Group was in-network but maybe the individual physician was new and had not been added under their group.  No, that is not the case the representative said.  I informed the representative I wanted to send the EOB and she said to mail it or fax it.  I said I can scan and email it but she said they would not accept that.  I then said thank you and hung up.

The next thing for me to do was to call my insurance.  I took a different tactic here.  I explained up front that I had 28 years of healthcare administration and billing experience.  I explained to the rep that I went to a hospital based ER that was in-network.  However, when I received the bill from the ER physician my insurance considered them out-of-network.  I asked the rep to confirm that the ER Group was in-network and that the actual ER Physician was in-network.  She stated both were out-of-network.  I asked her to send my claims to the Review department to have them reviewed and she said she would.

In the meantime I started searching the ole’ innerweb for information.  That is when I came across the Texas Department of Insurance and their mediation services.  I also found the Senate Bill (SB) 507 law enacted in 2017.

Surprisingly I received a call back the same day from my insurance, the same exact rep, indicating that they were re-processing the claim and would pay the ER Physician Group.  The rep would never confirm whether the Physician was in-network but she did say that insurance would pay them.  I assume that my insurance changed their position based on the SB 507 law.  SB 507 says that a bill resulting in $500 or more can be mediated – they paid $1,418 of the $1,902 bill, leaving $484.  Hmm….coincidence?  I think not.

What is interesting is that the EOB above still reflects that the ER Physician Group was still considered out-of-network……

So since my insurance re-processed the claim and paid the ER Physician Group I have not heard from the ER Physician Group at all about paying them.  I did receive a “Final Notice” statement about two weeks after they should have been paid which was interesting.  I do plan to contact both the ER Physician Group and my insurance again to follow up.

Final Notice bill

So, what can you do about Surprise Medical Bills?  I have come up with xxx number of key things you can do to prevent and manage Surprise Medical Bills.

How to prevent (or at least be aware).

1. Know your healthcare plan.

OK, you either signed up for your employer sponsored plan or purchased it yourself.  Before you did this, did you ask or look to see what medical providers are considered “in-network” under the plan?  If yes, great.  If not, you may be in for a costly lesson.

Before you sign up, you should always confirm what medical providers are in-network under the plan.  HMO plans are some of the most restrictive networks – they manage costs by managing a small network of medical providers.  PPOs typically have bigger networks of medical providers but you will run into situations like mine where some hospital based provider is still considered out-of-network.

How do you know?  During open enrollment these days insurance plans typically refer you to their online website to check networks.  In the old days you might have received a 100 page book instead.  Go onto the insurance plan’s website and search for your medical providers – remember to not only look at physicians but look at hospitals and specialists.

Extra Credit assignment – If you have a chronic health condition, also call all your medical providers to confirm with them that they accept your insurance.  Sometimes health insurance plans are behind on updating their lists.

2. Planned procedures.

After you discuss the need for a test or procedure with your medical provider, call your insurance plan yourself.  The doctor’s office and hospital will call your insurance plan to confirm eligibility but that only means they are confirming you have insurance coverage. 

Always call your insurance to ensure two things.  First, that the procedure is authorized.  See my post about Healthcare Code Breaker.  And even that may not be enough – also ask if there are other approvals needed (we learned a new term called “Medical Determination” which delayed Mrs. r2e from receiving a key drug in her chemotherapy treatment).

3. Emergency procedures.

You need to know you major in-network medical providers BEFORE you have to visit an emergency room.  Not all hospitals are considered in-network.  What is worse is that many of those ‘no wait’ freestanding EDs popping up all around town are notorious for being out-of-network, so your shorter wait may turn into a larger bill!

If you have HMO plan, stay in-network or else you most likely will be stuck with a big bill.  You are usually not protected even by federal or state laws if you willingly go out of network.  Now if the ambulance takes you and they do not give you a choice, you may have a chance to overturn bills.

This should go without saying, however, I will say it.  I am not a medical professional.  If you have what any prudent layperson would consider to be an emergency medical need, see out care at an emergency room right away.

4. Physician Group Issues.

You may run into a situation where paperwork has not caught up to the real world.  A large physician group may be in-network with a plan but when a new doctor joins, the paperwork takes time so early claims may not show that one doctor as being in-network.  Don’t freak out.  Be persistent.  Call the group practice and call your insurance until the paperwork catches up.

How to React if you get a Surprise Medical Bill

1. Know your State laws.

Through our situation I learned about SB 507 in Texas.  I also found the Texas Department of Insurance website through my insurance plan EOBs.  Google your own state name and ‘department of insurance’ and visit it.

2. Call your insurance plan

Your insurance plan should be your advocate if there is a billing problem.  Once you receive your EOB, call your plan to discuss and confirm what is going on if you see wording indicating a medical provider is out-of-network.

If you have done Step #1 and know your state laws that will help in your conversation.

3. Call the medical provider

Do NOT just pay the bill you get from them (my opinion).

You will need to call the medical provider who billed you.  Be nice about it.  Unfortunately in some cases the first (and maybe second) person you talk with will not have the knowledge to know what you are talking about.  Be persistent.  Ask for a Supervisor.  Offer to send your EOB (with out-of-network highlighted).

4. Do not give up. It will take time and effort.

I have invested about 4 hours of time on phones, writing emails, etc. on this one issue.  This is not something that you will get resolved with one five minute phone call.  Stick with it.  To have leverage in my conversations, I tell the insurance plan and medical provider that I am not paying a bill until I receive in writing a satisfactory answer to my questions.

What I still plan to do:  Contact my State Rep and others to draw attention to the problem with having out-of-network hospital based providers inside hospitals who are in-network.  The laws on “Consent to Bill” notices need to change.  It should be that hospital based providers are required to be in-network for plans the hospitals have.  No more Surprise Medical Bills.  That sounds anti-capitalist but what if you went to your auto mechanic shop and later learned that the actual individual mechanic is separate and sends you a big unexpected bill!  Crazy.

I encourage you to visit my Health Posts to check out what you can learn to become an educated healthcare consumer.

Have you ever received a Surprise Medical Bill?

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