Hold onto your wallet: Surprise medical bills and what to do about them

The Pennsylvania Insurance Department is holding a hearing on October 1 to consider the plight of patients who receive surprise medical bills. Those are bills for services the patient thought were covered by insurance but are not.  Consumer advocate Antoinette Kraus and Hospital and Healthsystem Association of Pennsylvania President Andy Carter offer advice on what needs to be done and what you can do if you receive one.

Antoinette Kraus, Director, Pennsylvania Health Access Network

Maria, a 22-year old home care attendant from Philipsburg, Pennsylvania, thought she was fully covered when she visited a local emergency room recently. Even though she needed care quickly, she made sure to ask in advance whether all of the care she was about to receive would be reimbursed by her insurance company. The hospital reassured her that it accepted her insurance and that everything would be fine. She paid her copay and thought she was done.

Three weeks later, a surprise arrived in the mail - a bill for $283 from one of the doctors who had treated her. Confused, she called to inquire about it and was told that as a subcontractor of the hospital, the doctor did not participate in her insurance plan. She had to pay up — the full amount — or face collection.

Maria was eventually able to receive reimbursement from her insurance company for the cost, but many Pennsylvanians are not so lucky. A study by the national consumer watchdog group Consumers Union found that one-third of Americans have been hit with a "surprise" medical bill, like Maria's.

When seeking care at an in-network hospital, clinic, or provider, most patients assume that everything will be covered. But out-of-network providers may render part of the care without the knowledge of the patient, who is then stuck with the bill.

Providers often charge more for services rendered out-of-network, because this care is not subject to the same contractual fee limits with the patient's insurance company as in-network care. Consumers are then left to fend for themselves. These "surprise" medical bills can cause a significant financial strain.

On October 1st, the Pennsylvania Insurance Department will hold a hearing in Harrisburg (State Museum, 300 North St.) to hear from consumers who have been hit by surprise medical bills. A variety of legislative solutions have been devised in several other states, including New York, California, and Texas, that hold consumers harmless when, despite having taken reasonable measures to use only in-network providers, they're hit with out-of-network charges.

In the meantime, what can patients in Pennsylvania do when a surprise medical bill arrives? They can contact the Pennsylvania Department of Insurance at 1-877-881-6388 or the Pennsylvania Health Access Network at 1-877-570-3642.

The Affordable Care Act has helped millions of Americans gain insurance, but there is still health reform work to be done.

Andy Carter, President & CEO, The Hospital and Healthsystem Association of Pennsylvania

You chose your health insurance plan carefully. You pay your monthly insurance bill, or premium.

You checked the deductible, co-pays, and co-insurance that your plan expects you to pay in addition to your premium.

You made sure that the doctors and hospitals you might need were in your insurance plan's network. (When doctors and hospitals are "in network," they have an agreement with your insurance plan about how much they will be paid. "Out-of-network" doctors and hospitals have no such agreement. As a result, they can bill you for the difference between what your plan paid them and what they think is fair.)

You still got a surprise bill? Ask for an explanation!

Do what you would do with any other bill that you don't understand, or that seems way out-of-line with what you expected. Ask for an explanation.

Start by calling the doctor, physician practice, or hospital that sent you the bill.

I googled "billing question" for six Philadelphia-area health systems. It was pretty easy to find a number to call for questions about bills. Make the call!

If necessary, you can and should also ask for help in working out a way to pay the bill.

You may very well have to call your insurance plan as well. Your insurer can explain your deductibles, co-pays, and co-insurance, and how these affect what you owe the hospital or doctor.

Is it an "out-of-network" issue?

Even savvy consumers who understand their health insurance plans and provider networks inside and out can be surprised by a bill from an "out-of-network" doctor or other health care provider. Unexpected bills from "out-of-network" providers can happen when:

How can we get rid of surprise bills?

Regardless of the reason for a surprise out-of-network bill, receiving one is a frustrating and upsetting experience.

Speaking on behalf of Pennsylvania hospitals, we hear you. We did consumer research to learn more about how the complexity of health care billing is affecting you.

We found out that for many of you, health care can feel complicated, confusing, and impersonal—"caught up in red tape." Billing issues are a big part of the problem.

Hospitals are working together to improve the situation. More than 70 percent of Pennsylvania hospitals have adopted these new principles and guidelines for billing and financial services.

The guidelines outline how hospitals should explain to patients what they will owe for their health care. Among other things, the guidelines say that hospitals should do their best to identify any out-of-network doctors or other providers that may be part of patients' care.

Please take a moment to read the guidelines. They'll help prepare you to talk with your hospital or doctor about what you should expect to pay for your health care.

Pennsylvania hospitals want to help you avoid that surprise bill. They want to do a better job of helping you understand their bills. A little push from you the consumer can only help!

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