Again, those who live in countries with universal health care can chuckle. Others can simply cry.
What is a surprise bill?
Health insurance in the US has migrated toward a “health maintenance organization” system. Doctors and laboratories who are in network agree to the fees allowed by the insurer, and are paid by the insurer. Doctors and labs that aren’t in network don’t accept the insurance fees, and aren’t paid by the insurer. Bills for those services go to the consumer.
Most consumers know to check the in-network status when making an appointment with a new doctor — or I help them by consulting insurer directories before they sign up for insurance.
How then can surprises happen?
- The doctor orders lab work and uses a lab with which he has a relationship, but the lab it out-of-network with the insurer. Doctors don’t know and often won’t check, so the patient ends up with a bill from the lab. The patient can try to submit the bill to the insurer, but the insurer is not obligated to pay it. According to a new report from the Journal of the American Medical Association, this is the most common form of surprise billing.(1)
- The patient goes to an ER or urgent care facility that is out of network. Now, if the patient is traveling away from home, that’s usually not a problem. Most insurance policies have provision for emergency care while traveling in the US. However, if the facility is local to the patient’s home, it can be a big problem. Again, if there is an in-network alternative, the insurer is not obligated to pay. According to JAMA, this is the second most common form of surprise billing.
However, these hardly exhaust the possibilities.
One I personally experienced was an outpatient eye surgery. The Ambulatory Surgery Center was in-network with my insurer, but called in an anesthesiologist who was out-of-network. I was already prepped for the surgery and on the gurney when I was asked if using an out-of-network doctor “mattered to me.” The choice was to postpone the surgery or use this doctor. Not knowing better at that time, I agree to go ahead. That was a surprise $4,000 bill that the insurer refused.
A new twist happened to a friend yesterday. The young may went for surgery, and the doctor — who was in-network with the insurer — demanded a $1,200 cash payment on the spot before starting the procedure. SURPRISE!
That doctor is trying to go around the agreement with the insurer. My guess is that he isn’t reporting this “pre-billing” so the carrier doesn’t know he’s breaking the contract.