What exactly is a surprise medical bill?

It’s hard to believe that there is actually a definition for a “surprise medical bill”.  There are real circumstances where a medical bill qualifies as a “surprise”, and the House Energy and Commerce subcommittee, and many states, would like to offer a solution for those who are faced with such surprises.

First, let’s describe what a surprise medical bill is. If you receive services from a hospital or ambulatory surgical center that is part of your plan’s network, the bill will be considered a surprise bill if:

* A participating doctor was not available, or
* A non-participating doctor provided services without
your knowledge, or
* Unforeseen medical circumstances arose at the time
the health care services were provided.
* It will not be considered a surprise bill if you choose to
receive services from a non-network doctor instead of
from an available network doctor.

Most often, surprise medical bills are a result of emergency surgery or being rushed to a nearby hospital for urgent care. It is also possible for a bill to be considered a surprise bill if you are referred to a non-network provider and you don’t sign an acknowledgment that these will be non-network services.

Confused? Of course you are! How can you sign an authorization or determine if you’re using a network provider if you’re unconscious? Or if it is a dire emergency with no time to spare?

There are some ways to remedy a surprise medical bill. Depending upon your state and if your plan is state regulated, you may be able to sign an Assignment of Benefits. You need to send this form to your provider so that the provider is permitted to seek payment for the bill AND send the form to your health plan and provider including a copy of the bill in question. More than a dozen states have passed legislation attempting to remove the individual from being in a position to have to negotiate bills for health care.

That said, if your plan is self-funded, and, therefore, federally regulated. you will not be able to use this remedy to address your surprise medical bills. However, there may be hope on the horizon: the House Energy and Commerce subcommittee is trying to address surprise medical bills–although they appear to be split (not along party lines) about whether to give doctors and hospitals a chance to arbitrate balance billing disputes. The Senate Health Committee is looking at this also.

Some ancillary advice: If you’re going to see a doctor for any reason, be sure that any blood work is sent to an in-network lab. The cost of blood work can be staggering and it’s critical that your blood be sent to an in-network lab. Also, be sure that everything you use is in-network before you do ANYTHING. No one wants surprise bills if they can be prevented.

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