Surprise Medical Bills: Gaps in Health Insurance
The Californer/10253167

NEWPORT BEACH, Calif. - Californer -- Common Types of Surprise Bills and Gaps in Coverage

• You had surgery at an in-network hospital, but the anesthesiologist was not in your health insurer network. The anesthesiologist will send you a bill.
• You went to an in-network lab or imaging center for tests and the doctor who read the results is not in your insurer's network. That doctor will send you a bill.
• You may have Medicare and supplemental insurance but neither one will pay the medical bills in full if you get treatment for, say, cancer.
• A consumer who is taken to the nearest emergency room may also receive a bill from the emergency facility for the remaining balance of the bill that was not paid by their health plan.
• A mistake in billing by the medical provider or coverage group.
• 20% of surprise bills were a result of a doctor not being part of the network.
• 53% of surprise bills were for a healthcare provider while 51% were for lab tests.
• 43% of surprise bills were hospitals or other health care facility charges.
• 35% of surprise medical bills were for imaging and 29% were for prescription drugs.

Some states, like California, have passed a law which prevents providers from sending surprise bills when they use an in-network facility. However, some states do not. Even if your state does not have this type of law, the Federal No Surprises Act protects patients from many of these types of surprise bills as well.

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As for copayments that go with expensive treatments, there will be a gap in insurance, even if you try to fill the gaps. And the gaps may be as high as $1,000 in out-of-pocket expenses each month!

Also, experimental treatments are almost always excluded from coverage. People also lose sight of the fact that certain medical services, like physical therapy, have maximums, even if prescribed by a doctor. Once you reach the policy's limit, you will have to pay for sessions on your own. Note that out-of-network maximums can be significantly higher than in-network ones, sometimes twice as much.

A medical-billing advocate may be able to help negotiate down out-of-pocket expenses and set up a manageable payment plan if you're unsuccessful in getting the cost waived. But you must act before the bill goes into collections, at which point it will no longer be in the hands of the provider.

Do you have gaps in your health insurance coverage? Visit https://smartfinancial.com/health-insurance to compare health insurance rates now or come Nov 1 during Open Enrollment. It's free!