Managing Surprise Medical Bills

Writing about health insurance and health care issues cannot be done without reference to politics. This segment of the economy is highly regulated and there is never a time when new laws aren’t being proposed.

The good news is that it appears there is bi-partisan support for federal legislation that will eliminate surprise medical bills. Maybe this will be good practice for legislators to remember how to work together!!

Californians can be grateful that our stated implemented this type of regulation in July of 2017.

Surprise medical bills can take several forms. One might be that an individual has surgery at a hospital that is in the insurance plans Preferred Provider network, but the anesthesiologist was not in network. The anesthesiologist then bills much more than the plan allows and the employee is balance billed for more than their share of the plan’s negotiated rate.

The patient had no control over who delivers the anesthesia and had no way of knowing the doctor was not in the network. When the provider send the extra bill, the patient is surprised…and often quite upset.

If a patient goes to a lab that is in the plan’s network, but the provider who reads the results is not in the network, the patient could receive a surprise bill.

According to the California Dept. of Managed health care, “Under AB 72, consumers should no longer receive these surprise bills. This means when you go to a health care facility like a hospital or a lab in your health plan network, and end up with a doctor who is not in your health plan network, they cannot charge you more than you would have to pay for an in-network doctor.”

If an individual has received a surprise bill paid more than the in-network cost share there are remedies to obtain a refund. The insured may file a grievance with the health plan. This may be done in writing or in some cases simply by calling the customer service number on the plan’s ID card.

If the results of the grievance are not satisfactory, one may file a complaint with the Department of Managed Health Care, (DMHC). This agency is the state regulator of health plan. The website address is: www.HealthHelp.ca.gov and the phone number is 1-888-466-2219.

It’s important to understand that this law applies only to individuals insured by health plans regulated by the Department of Managed Health Care or the California Department of Insurance. It does not apply to Medi-Cal plans, Medicare plans or “self-insured plans.” If the plan type is unclear, the health plan’s customer service number may have the answer or one can call DMHC at the number above.

These rules do not prohibit an individual from voluntarily seeking care from an out of network provider. It is important to check the plan provisions to see how out of network care is covered. There may be separate deductibles for out of network providers. There will likely be a much greater co-insurance or copayment paid by the individual when using an out of network provider. It is important to understand the costs before you choose to go to an out of network provider. The provider should be able to give you an estimate.

Another option would be to request the actual procedure billing codes and charge from the provider, then call the health plan and ask what the share of cost would be based on that information. This will prevent those unwanted surprises.

Margaret R. Beck
Margaret Beck  CLU, ChFC, CEBS started her insurance practice in Redding in 1978. As an insurance broker/consultant,  she represents businesses and individuals as their advocate.  She assists in choosing proper products, compliance with complex benefit laws and claims issues once coverage is placed. All information in her column is provided to the best of her knowledge, subject to final regulation by the respective agencies. Questions to be answered in this column can be submitted to info@insuranceredding.com. Beck's column is also published in the Redding Record Searchlight.
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11 Responses

  1. Avatar Bruce Vojtecky says:

    I found that in Wyoming/Colorado going to the emergency room that, like most hospitals, the emergency room was contracted out to a private contractor and there were surprise billings. When UC Health bought most of the hospitals, clinics in the state the private contractors were eliminated. No more surprise billings. Now that I am in Arizona there is no UC Health. I went to Banner and they told me everything was covered but when I went to the emergency room I got surprise billings because of private contractors.

  2. Avatar erin friedman says:

    Our surprise bill came from my husband’s primary care provider – a doc we chose from a list provided by Blue Shield. Blue Shield now insists he is not a preferred provider. The doc’s office insists he is. So we continue to go round and round, getting nowhere.

  3. Adrienne Jacoby Adrienne Jacoby says:

    And cruelest joke of all?
    As we get older and older, we need more and more of this care, we become less and less willing (or able) to deal with the vagrancies of the system.
    The idea of wandering off somewhere in a frozen countryside becomes more and more understandable.

    • Avatar Bruce Vojtecky says:

      When I was much younger I had a customer who was 80. He sometimes talked about how he was ready to wander off in a frozen countryside. Now I know how he felt.

  4. Joanne Snyder Joanne Snyder says:

    Adreinne’s comment is the truth. The customer (patient) should not have to waste their time doing battle with 1st tier “just say no” phone operators for insurance or medical providers for basic information or assistance.

    • Avatar Beverly Stafford says:

      Something that drives me nuts is to go to a doctor and again have to complete the same multi-page form that I’ve completed every time I’ve had an appointment. Name? It’s still the same. Parents? Still dead from the same cause. Surgeries? Tonsils are still gone. Then the nurse goes over the form making notes. And once the doctor gets the form, she asks something to the effect, Now tell me everything you just told the nurse. Maddening. Just give me last year’s form and let me make any changes if there are any.

      And then there’s that circus when you need to see the specialist that you’ve been seeing for 20 years, but since it’s been a shade over two years since your last visit, you have to be referred by your GP. And Joanne’s “just say no” front desk person says, as she’s walking away, “That’s a Medicare rule.” After 20 years?!

  5. Avatar Bruce Vojtecky says:

    The main thing I miss about living in Wyoming is UC Health had everything on their computer at all offices, hospitals, clinics. They had my insurance, prescriptions, doctors all ready there. All they would ask me is if there had been any changes. I paid a $10 co-pay for all services, no surprises.
    Why can’t all Healthcare providers do that?
    Eventually I will move back there, that is where I want to die. Having morning coffee watching the snow capped peaks of the Rockies.

    • Avatar Bruce Vojtecky says:

      Side note to Steve Towers. I envy you if you are going to retire back to Colorado. UC Health is available in all of Colorado, urban and rural.

    • Avatar Beverly Stafford says:

      Such a civilized way to handle our health. When will they ever learn . . .

  6. Avatar Amy Curran says:

    I got 2 surprise bills after a trip to the ER in January. My insurance did not consider passing out due to dehydration an emergency. I had to appeal that decision. At the same time the nurse practitioner who treated me was in a group that isn’t a preferred provider. I had to negotiate that bill. Every time I have to deal with something like this it strengthens my belief in healthcare for all under a one payer system.

  7. Avatar Candace C says:

    I currently have a great insurance plan but doctor accessibility ain’t so great. One trusted family doctor I’ve had for years takes no insurance and charges aprox. $90 per visit. They are not in office Thursday’s, are closed on weekends and take fairly frequent vacations. The upside is that they are trusted, conveniently located and I could typically get in same day, without a previous appt if I needed to (if it wasn’t a Thursday, weekend, etc.) So I’m trying a doctor that is In Network with my insurance. This doc and their nurse are great (and the office is open Mon. thru Sat.) but in a group practice and it’s almost impossible to get a human on the phone to make an appt. When I do get through there are typically no openings sooner than a month out. So my choices are to pay more than I can afford, wait weeks to get in, or go to an urgent care facility. Not ideal and while I’m thankful for the fact that I at least have choices available to me, my guess is that these are a few of the reasons some of us sometimes wait longer than we should to call our doctors when we think something is wrong. I know I do.