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How to Prevent and Deal with Surprise Medical Bills

January 24, 2020

Reminder – California law protects consumers from Surprise Medical Bills, sometimes also referred to as Balance Billing

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 co-pay or shared co-insurance percentage. But after the surgery you get a bill from a doctor who isn’t in your network. This is a surprise bill which also often happens in connection with emergency services.

The law protects consumers from surprise medical bills like this when

  • A health plan member goes to an in-network facility such as a hospital, lab or imaging center, but services are provided by an out-of-network health provider.
  • A health plan member receives emergency services from a doctor or hospital that is not contracted with the patient’s health plan or medical group.

This consumer protection in California makes sure health plan members only have to pay their in-network cost sharing (co-pays, co-insurance or deductibles). Healthcare providers cannot bill consumers more than their in-network cost sharing.

What is a Surprise Medical Bill?

A surprise medical bill occurs when you go to a health care facility, like a hospital or a lab in your health plan’s network (a network is the group of healthcare providers who’ve agreed with your insurer to accept a set of discounted rates for services), and you end up with a doctor who is not in your health plan’s network and you are charged more than you would have to pay for an in-network doctor.

A surprise medical bill can also happen if you are taken to a non-contracted facility in an emergency, and the facility bills you for the remaining balance for the services you received that were not covered by your health plan.

What You Should Pay

Consumers who go to an in-network facility only have to pay for their health plan’s in-network cost sharing amounts.

If a consumer is taken to a non-contracted medical facility for emergency services, the consumer will only be required to pay in-network cost sharing amounts.

Here are some examples of when consumers have received surprise medical bills:

  • A consumer had a surgery at an in-network hospital or outpatient surgery center, but the anesthesiologist was not in their health plan network. Even though the consumer did not have a choice of who their anesthesiologist was, that healthcare provider sends a bill charging above the in-network cost to the consumer for their services after the surgery. This is a surprise balance bill.
  • A consumer goes to an in-network lab or imaging center for tests and the doctor who reads the results is not in their health plan network. that doctor then bills the consumer for their services, creating a surprise balance bill.
  • A consumer is taken to the nearest emergency room, however, the emergency facility is not contracted with the consumer’s health plan. The consumer later receives a bill from the emergency facility for the remaining balance of the bill that was not paid by their health plan. This is a type of surprise bill known as emergency balance billing.

What if I get a surprise bill?

If you get a surprise bill for more than your in-network cost share, file a grievance/complaint with your health plan and include a copy of the bill. Your health plan will review your grievance and should tell the provider to stop billing you. If you do not agree with your health plan’s response or they take more than 30 days to fix the problem, you can file a complaint with the Department of Managed Healthcare, the state regulator of health plans. You can also file a complaint by visiting www.HealthHelp.ca.gov or calling 1.888.466.2219.

We are pro-actively assisting our clients with these claims so feel free to contact us now to help work through this often frustrating billing issue with you or your employees!