Imagine you go to a hospital for a routine procedure. You’ve made sure your hospital and doctor are covered by your insurance. The procedure goes well and you head home to recover.
Two weeks later, you get the bill, but instead of the copay you expected, you get a bill for nearly $4,000. Turns out, the anesthesiologist who assisted with your procedure was “out of network” and your insurance won’t cover that bill as expected.
You’ve received a surprise medical bill and now owe the difference between what your insurance will pay the out-of-network anesthesiologist and what you were billed.
What is a “surprise” medical bill?
You receive a surprise medical bill when, through no fault of your own, you are treated by providers outside of your insurance network.
These out-of-network providers can charge exorbitant rates only revealed when the bill arrives in the mail. When out-of-network providers charge these high rates, it drives up costs for everyone.
How to prevent a surprise medical bill
The best way to prevent a surprise medical bill is to do everything you can to avoid being treated by an out-of-network provider. Here are a few important steps you can take:
Check with your insurer to make sure you are choosing a hospital, health care facility (lab, diagnostic center, surgery center), and doctors that are in your insurance network before receiving treatment; when planning hospitalizations at an in-network facility, check with the facility to be sure that all providers (surgeons, anesthesiologists and others), lab services and imaging services are covered by your insurance plan; and know where your nearest in-network emergency room is for those times when it is possible to choose.
Know your rights
Arizona has a law that allows patients to dispute a bill from an out-of-network provider for treatment at an in-network facility if it amounts to $1,000 or more, after subtracting your cost-sharing amounts (copay, coinsurance and deductibles).
If you get a surprise medical bill, you can file a request for dispute resolution (arbitration) with the Department of Insurance and Financial Institutions.
Tips for lowering a medical bill
If your bill does not qualify for arbitration or your plan is not protected by state law, you should still try these tips to lower a medical bill:
Ask for an itemized bill and check that you are not being mistakenly billed for treatment you did not receive; compare the itemized bill to your Explanation of Benefits to see whether your insurer is paying its share; contact your provider and ask about anything you don’t understand; contact your insurer to see if any mistakes were made on their end; and keep careful notes of all conversations you have including the name(s) of the person.
The Arizona PIRG Education Fund has additional tips and information from filling out a request for arbitration to insurance coverage that protects consumers from a surprise medical bill at www.ArizonaPIRGedfund.org. Check it out and protect yourself and your wallet.
Patricia Kelmar is the health care director for the Arizona PIRG Education Fund. The Arizona PIRG Education Fund conducts research and education on issues in the public interest.