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Sha'Ron James

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States Work to Limit Out-of-Network Medical Bills

News Article

April 03, 2016

Consumer Reports

The last thing you’re likely to think about if you’re having surgery is whether every single doctor that attends to you is covered by your insurance plan. Even if your hospital accepts your insurance and your orthopedic surgeon is covered, the anesthesiologist, for example,may not be. And that could be costly.

When an out-of-network doctor operates on you, you will likely get a bill for the amount your insurance company won’t cover, a practice known as balance billing. But because out-of-network medical bills can run 10 to nearly 100 times more than the rates set by Medicare, according to ananalysisby America’s Health Insurance Plans, you could end up with a hefty bill.



Florida is in the process of putting an end to that. The state recently passedlegislation that limits the charges consumers face when they have no choice but to use out-of-network medical providers. It would leave insurers and healthcare providers to settle such disputes. Thebillwas submitted to Governor Rick Scott on March 30 and he has 15 days to sign or veto it. If he does nothing, the bill automatically becomes law.

Twenty three states in all are currently working towards or already have some consumer protections against surprise medical bills. One of them, New York, has among the strongest consumer protectionlawsfor out-of-network billing in the country. Itwent into effect last April. The law requires that patients in emergency medical situations pay no more to out-of-network providers than they would have paid to those that are in-network. If there is a dispute over medical bills, the consumer doesn't have to handle it. It must be settled between the insurer and the medical provider.

President Obama has also proposed in his 2017 budget for Health and Human Service aprovisionto end surprise out-of-network medical bills. Separately, the Center for Medicare and Medicaid Services now requires disclosurewhen an out-of-network physician will be providing services to protect consumers from surprise billing in emergency situations.



While the states are making progress to protect you, you can help yourself as well. Before you go to the hospital:

  • Check that the healthcare provider or hospital you use has a contract with your insurer that makes it "in-network".
  • If you have a planned surgery, ask your primary doctor whether there will be other doctors or services involved in your treatment. Then call your insurer to check if they are also covered by your plan.
  • If you are charged for out-of-network expenses that were beyond your control ask your healthcare provider if she will take a lower payment so that it’s comparable to an in-network price.
  • Ask your insurer to negotiate with the doctor on your behalf. If that doesn’t work, file an appeal with your insurer. If the insurer denies your appeal, file a complaint with your state insurance regulator.

To find out which protections your state offers or where to file an appeal if an insurer denies your claim, use Consumer Reports' online tool and check this state map that tracks surprise medical bill legislation.