When it comes to medical billing, transparency is vital. Individuals undergoing an emergency procedure or surgery often face heavy financial burdens through co-payments and deductibles alone; the stress and anxiety of recovering both physically and mentally from a medical issue already takes a tremendous toll. The last thing a patient needs or wants to deal with when recovering is an unexpected medical bill.
Balance billing occurs when a health care provider bills a patient for the difference (the balance) between the provider’s charge for a service and the insurance plan’s payment for the service. The term “surprise medical bill” is used to describe a balance bill that a patient did not expect to receive.
Right now, there’s a bipartisan effort in our nation’s Capital to solve the issue of surprise medical bills. One encouraging sign is that policymakers are focused on keeping patients out of the middle of billing disputes between providers and insurance companies.
Recent research has shown a rise in surprise out-of-network charges for inpatient care. According to a recent study from researchers at Stanford University School of Medicine, surprise out of network charges for inpatient care more than doubled between 2010 and 2016. In another study conducted by Johns Hopkins University, data revealed that the physician specialties most likely to send surprise bills are anesthesiology, interventional radiology, emergency medicine, pathology, neurosurgery, and diagnostic radiology, but occur in almost all medical settings regardless of provider type.
As a matter of fact, a study of insurance claims data from large employer health plans by the Kaiser Family Foundation found that roughly 1 of every 6 emergency room visits and inpatient hospital stays in 2017 resulted in patients receiving at least one out-of-network medical bill. That amounts to 18 percent of all emergency visits and 16 percent of in-network hospital stays.
Anna Legassie knows this scenario all too well. She lives with rheumatoid arthritis and has been on the receiving end of unexpected medical bills. In 2018, she ended up having to go to the emergency room twice within a 2-month period.
“I did all of the things I’m required to do to ensure I was seeing the providers that I’m supposed to, based on my insurance and in-network plan,” says Legassie. “In both instances, I received unexpected medical bills for going to my in-network hospital totaling $3,000.”
Arthritis Foundation Board of Director Dennis Ehling has also experienced surprise medical billing in his family: his young adult son needed major back surgery. The family did their due diligence to specifically choose the doctors and hospital for the surgery to ensure it would be considered in-network; they also made sure everything was pre-authorized to avoid any surprises.
“We pre-cleared the surgery and all of the expenses with our insurance company,” said Ehling. “We were by my son’s side the entire time he was admitted. Throughout it all, no one ever mentioned that any of his treating doctors might not be in-network.”
A month later, the Ehlings received a bill from the hospital with an uncovered charge for an anesthesiologist who had stopped into the recovery room early in the morning for a post-surgery check-in.
“The anesthesiologist who made a simple check-in, for whom we had no notice and no choice, was out-of-network and, thus, we were initially billed more than $1,000 for that visit, before we were able to ultimately convince them to treat it as in network,” said Ehling.
There ended up being two out-of-network doctors who treated his son – an anesthesiologist and a neurosurgeon, who either assisted or did a follow up visit. They did not know another neurosurgeon would be seeing their son. That bill was submitted for more than $3,000. After months of arguing about the charge, they were able to reduce the cost to just over $600. However, it was still an amount they did not expect to pay in addition to the costs they had already estimated prior to surgery.
Both stories are not unique to those living with arthritis or other chronic diseases. Millions of other people with chronic diseases visit emergency rooms or require surgery and experience surprise medical bills every year. The Arthritis Foundation is tackling the issue of surprise medical billing and advocating for reforms that fully hold patients harmless.
For instance, people with arthritis who receive out-of-network care, through no fault of their own, should pay no more than the in-network cost sharing amount, such as deductibles, coinsurance, or co-payments that are expected. The Arthritis Foundation also advocates for surprise medical billing protections that should apply to all types of health insurance plans. Any potential policy solution should ensure that insurance premiums and overall patient costs do not increase as a result of any policy solution.
Take action today!
Now more than ever, your voice can make a difference. Contact your members of Congress to share your experiences of surprise medical billing today! By sharing your story, lawmakers who are exploring solutions to this issue can better understand how this problem has affected you. Help put an end to surprise medical bills.
While our lawmakers are working together to address these issues and agree on a bipartisan solution, you can read about some tips to avoid getting a surprise bill for your arthritis care. You can also help the Arthritis Foundation and patients like you by sharing your surprise medical billing story through our Story Bank.