A surprise no one wants: Big medical bill even with coverage

This winter's nasty flu season may smack patients with a financial side effect: surprise medical bills.

People who wind up in the emergency room or need an ambulance can be blindsided by hefty, unexpected charges. This often happens after patients visit a doctor or hospital outside their insurance network so coverage was limited. Insurance deductibles that reset every January and must be paid before coverage begins can make these invoices even more painful.

Here's a look at the issue and some tips for dealing with surprises:

COMPLICATED NETWORK

Insurers form networks of doctors, hospitals and others and then negotiate rates with them. Doctors cannot bill outside those agreed-upon rates for in-network care.

For out-of-network care, providers can bill patients the difference or leftover balance between what the insurer paid for the care and what was charged.

On top of that, many insurers also make customers pay separate, higher deductibles for out-of-network care before they provide coverage. Then they tend to cover less of the remaining bill than they would have for in-network care.

The end result could mean a bill topping several thousand dollars, depending on the coverage and the care a patient needs.

Some plans even provide no coverage for non-emergency care outside their network. That's more common with individual coverage sold on the Affordable Care Act's insurance marketplaces.

Networks in those marketplaces also have gotten particularly narrow in recent years, which makes it easier for patients to end up with an out-of-network provider.

SOURCE OF CONFUSION

People with flu symptoms have been flocking to ERs in several states this winter, and that can lead to surprise bills, in part because patients are focused on getting help and not always researching their coverage. Even if a patient choses an in-network hospital, the doctor delivering care may be out of network.

For more complicated cases, the odds of that happening increase. A doctor assisting in a surgery may be out of network, and so might the anesthesiologist. A woman may give birth with help from an in-network doctor. But the baby may wind up in neonatal intensive care, where a doctor outside the network treats it.

Ambulance rides are another case where a patient may have little control over who provides the care.

"You call 911, and the ambulance that shows up is the ambulance you take," said Erin Fuse Brown, a Georgia State law professor who researches medical billing.

WAYS TO HANDLE SURPRISES

If you're having a planned surgery or procedure, check ahead with both your insurer and the hospital or doctor to make sure they are in network. Also ask about any physicians that may assist with the procedure.

If you wind up with a surprise bill, check first for errors in what was charged or if you have been billed out of network by mistake.

Then ask if the claim can be processed again as in-network care, especially if you had no way of knowing it wasn't beforehand.

If that fails, some hospitals may be willing to negotiate discounts or put you on a payment plan.

In some markets, the law may be on your side. New York, California and several other states prevent providers from dropping surprise bills on patients unless the person had agreed to out-of-network care ahead of time.

But there are no federal laws that govern surprise medical bills, and those state laws don't apply to some forms of insurance like the coverage millions of people receive from large employers, said Kevin Lucia of Georgetown University.

At the very least, don't ignore a surprise medical bill. A hospital may report your account to a credit agency or turn it over to a debt collector who sues or tries to have your wages garnished.

"It's not going to go away," said Fuse Brown.