How to Prevent—and Deal with—Surprise Bills

You’ve prepared for your surgery. You’ve checked that your surgeon and hospital are in your health plan’s network. You’re ready to pay your required copay. But after the surgery you get a bill from a doctor who isn’t in your network. This is a surprise bill—which you also can get in connection with emergency services.

Surprise bills may happen because some of the providers caring for you during a procedure are unexpectedly not part of your plan’s network. (A network is the group of providers who’ve agreed with your insurer to accept set rates for services.) Even if the hospital where you get care is in your network, some of the providers there may not be. For example, your anesthesiologist, radiologist or pathologist may be out of network. If they bill you, they do so at their out-of-network rate, which is usually higher than in-network rates. Your plan may cover out-of-network expenses, but the cost to you will typically be higher than if you were cared for in network. And if your plan doesn’t have out-of-network coverage, you may have to pay the whole bill.

You may also get a surprise bill for an emergency room (ER) visit. In an emergency, you may be taken to the nearest hospital, even if it isn’t in your network. Even if the hospital is in your network, the ER doctor or other specialist in the ER (e.g., plastic surgeon) who cares for you may not be.

Members of the US Congress have been trying to pass federal legislation to protect consumers from surprise bills, but to date nothing has been finalized. Some states already have such laws, such as, for example, Connecticut, New Mexico, New York and Texas, and additional states are considering them.

Wherever you live, there are ways to lower the risk of getting a surprise bill. If, despite your efforts, you get a surprise bill, there are ways of dealing with it to reduce your costs.

Preventing Surprise Bills
Preventing surprise bills is always better than having to face one. If you’re planning surgery or another medical procedure, try, if possible, to make sure in advance that all your providers are in your network. Check with your insurer and the providers you know about, such as your doctor and hospital. Ask these providers to try to arrange to have in-network providers take part in your care. Make these requests in writing so you have documentation.

When asking questions and making requests, always call your plan by its exact official name. Insurers often have several plans that have similar names but different networks. If your plan offers different “tiers,” be sure to identify your own. Using the right plan name will help you get the right answer.

Dealing with Surprise Bills
If you do get a surprise bill, don’t let it sit there. If you wait, the bill may get sent to a collection agency, which can hurt your credit score. Or the provider may sue to collect.

Instead, take action yourself. Check with your state insurance regulator to see if your state has any laws protecting consumers against surprise bills for out-of-network services in an emergency or other situation. Generally, such laws provide that the consumer has to pay only the amount he or she would owe if the services had been received in network. States have different means of settling the balance of the bill. But they typically involve the insurer and provider, not the consumer.

If your state doesn’t protect you against the surprise bill you received, you have some options. First, check to make sure the provider really isn’t in your network. The billing company or back office that processed your bill may have made a mistake. Providers who are in your network have to accept the rate they agreed to with your insurer.

If the provider really is out of network, you can try to negotiate a lower rate. To prepare, find out what the typical rates are for the billed services in your location. You can do that with our FAIR Health Medical Cost Lookup Tool. If the provider’s charge is higher than the typical rate, you can use this information in negotiating with the provider. For example, you can ask if the provider will reduce the charge to the typical rate. For more, see our article Using FAIR Health Cost Estimates to Negotiate the Costs of Care.

If your plan has out-of-network coverage, the cost lookup tool may also be useful. You may find that your plan’s out-of-network reimbursement is based on less than the typical charge for that service in your area. If so, you can ask your plan to pay on the basis of the typical rate.

Suppose neither your provider nor insurer agree to your request. In that case, consider getting help. If you’re insured through your employer, ask your employer’s human resources department to assist. Or contact your local consumer protection office. You may even consider taking the provider to small claims court to allow the court to determine a fair price. You have various options against surprise bills.