About Surprise Bills
“Surprise bills” are charges billed when an insured person gets treatment from an out-of-network provider due to any emergency situations. Surprise bills are very common when you visit an emergency room, or inpatient facility, the reason is when in an emergency situation you completely miss to cross check if the provider is in-network, similarly, when availing inpatient services there are chances that your attending physician is not in contract with your insurance through the hospital or the practice is under your insurers’ network.
You can get a surprise medical bill when:
- You are on a vacation and have no access to an in-network provider and get treated by an out of network provider.
- You select an in-network hospital or practice, however later find out that your physician is not in-network with your insurer.
- Services received from an out-of-network provider, emergency room, ambulatory services or ambulance provider lead to Surprise bills as they are not accepted by your payor
- The provider you know for years is no longer in-network with your insurance and misses to inform you about the changes.
- Your Primary Care Physician (PCP) refers you to an out-of-network specialist and you miss to check if the specialist is in-network for your insurance to cover your bills.
Unexpected and Unaffordable
Surprise billing expense has become one that most people dread about because of two major reasons:
- Because of the higher amount the practice or physicians bill them. An in-network provider is in contract with your insurance company for negotiated charges and bills accordingly. However, out-of-network provider is not in any such contractual agreement with the insurance company hence the billed amount are comparatively higher than what the patient can afford.
- Another reason being, Surprise bills come as an unexpected and additional cost to their existing insurance plans and mostly these Surprise bills are unaffordable by the common man.
Ways to Avoid Surprise Medical Bills
Do A Thorough Check Before Availing Any Planned Healthcare Services:
- Before getting any planned medical services, ensure that the hospital and all the providers, attending or providing the treatment are in-network and current with your insurance company. Keep in mind, to cross-check every time you avail the services as there are chances that the hospital or physician who has been in the network are not accepting your insurance anymore.
- Even before getting any emergency services if possible inform your attending physician about your insurance and your preference to be treated by an in-network provider to avoid unwanted bills.
- While making an appointment, make it a practice to check the provider and network details to avoid last minute hassle and confusion.
Things to Note if You Receive a Surprise Bill
In case you have got services from an out-of-network provider and ended up getting an unexpected “Surprise bill” note the below points on how to handle the situation:
- Contact your service provider and try to negotiate on the billed amount.
- Check on the available payment plans
- Contact your insurance company and explain your emergence situation and see if they can help or negotiate with your physician.
- Appeal with the state insurance department as they can negotiate on behalf of you with your provider or with your insurance company.
Latest Update – New Agreement released on 11th December 2020 – Protecting Surprise Bills
The State law and Federal Legislation have been constantly protecting consumers against Surprise Bills by enacting laws to control such instances, however not every state had effective methods and rules to limit private physicians and hospitals from Surprise billing and Balance Billing. When it comes to protection of the patients against surprise bills each State varies in terms of its limitation and regulation and had its own limitations. However a new agreement has been released in Dec 2020 by both the Federal and State government according to which:
- Patients would be responsible for cost sharing only for in-network coverage bills in both emergency and certain non-emergency cases, where the patient do not have a choice of selecting an In-network provider.
- Out-of-Network providers are prohibited from billing their patients for the balance unless the patient was informed 72 hours in advance about their coverage status with the estimate charges and received the patients consent to receive out-of-network services.
- In-case the patient was not informed 72 hours in advance, the bill needs to be resolved by the insurers and providers or by an independent dispute resolution process.
To know more about the recent update on Surprise bills and how to avoid, reach out to MGSI so that you can educate your patients also we can help you with your billing.
About MGSI
MGSIwith over 25 years of experience in the industry provides successful healthcare revenue cycle management services to more than 600 physicians across US. MGSI has hands on experience working on various medical billing software and expertise handling major specialties. Compliant with HIPPA, and certified by LIVE Compliance to protect its network security and PHI matters; MGSI ensures to offer you the best outsourcing experience. To know more about MGSI log on to https://www.mgsionline.com