Whether you’re a person who loves surprises or they just aren’t for you, we can guarantee there’s one type of surprise that no one likes: surprise medical bills. Unfortunately, they’re a relatively common problem.
According to the Kaiser Family Foundation External Site, 20 percent of emergency claims and one in six in-network hospitalizations include at least one out-of-network bill External Site. A Harris Poll conducted for the American Heart Association External Site® found that two-thirds of U.S. adults with private health insurance have received an unexpected medical bill — one-third of whom were unable to pay it.
Receiving medical care (especially in a lifesaving emergency) can already be stressful without worrying about an unexpected bill. Luckily, there are ways to prevent surprise medical bills in the first place — and options if you do get one — before the No Surprises Act External Site goes into effect in January 2022.
What are surprise medical bills — and why do they happen?
Surprise bills, also known as balance billing Opens New Window, are medical bills you receive from physicians or facilities outside your health plan’s network. Surprise bills aren’t a result of being overcharged by a doctor or hospital.
These larger-than-expected medical bills happen when out-of-network health care providers bill you for what your health plan didn’t cover. This difference in what your health care provider charges and the amount your health insurance covers is known as balance billing and can vary based on your coverage.
Usually, most people don’t receive care out-of-network on purpose. Surprise bills can happen for a number of reasons External Site, including:
- Previously in-network providers becoming out-of-network (this could happen if you switch employers or change your health plan)
- Going to an out-of-network hospital when it's not an emergency
- Going to an in-network hospital but receiving care from out-of-network providers
- Not realizing specific lab tests, products, or procedures are not covered under your health plan
- receiving out-of-network medical transport via ambulance or helicopter in a lifesaving emergency
- Coding errors on medical bills (according to Healthline External Site, up to 80 percent of medical bills contain mistakes)
How to avoid a surprise bill
There are many ways to shield yourself from potential surprise bills.
- Know before you go. Before seeking routine care from any provider, double check they’re still in your network — even if they have taken your insurance before. If you’re planning a hospital stay at an in-network facility (like giving birth or having non-emergency surgery), make sure all providers you plan to see (including surgeons and anesthesiologists), along with lab and imaging services like blood work, X-rays, and MRIs are also in-network with your insurance.
If you’re a Wellmark Blue Cross and Blue Shield member and are curious about what a certain medical service will cost, you can register for or log into myWellmark® Opens New Window to estimate costs for common procedures.
- Make it clear you want to stay in-network. If your provider orders any tests like blood work or imaging services during a routine visit, be sure to clarify that you’re being sent to in-network labs or facilities to avoid out-of-network charges.
- Be prepared in case of emergencies. You should always know where your nearest in-network emergency room is, whether you’re at home or on vacation. And, because ambulance rides are generally pricey and out-of-network, you can call the fire department to find out which ambulance service responds to your neighborhood and figure out if they’re in your health plan network.
- Keep detailed records. If you’ve received a cost estimate for a certain procedure from your provider, keep it on file for six months to a year afterward in case you need to appeal a surprise bill. You’ll also want to save any bills for services you receive and Explanations of Benefits (EOBs) from your insurer, which you can compare to make sure they match and don’t contain any errors. You can access all your EOBs digitally Secure through myWellmark to save paper and space — EOBs are available digitally for 24 months after they’re produced.
- Understand what your insurance does — and doesn’t — cover. Knowing exactly what your health plan covers and the amounts you owe for services can help you avoid surprise bills. You can find your full Coverage Manual to download on myWellmark, in addition to several tools to help you understand how close you are to reaching your deductible, if you have one, or your out-of-pocket maximum.
What to do if you receive a surprise medical bill
Sometimes, surprise bills can slip through the cracks even if you’ve done all the preventive work ahead of time. If you find yourself facing a surprise bill, don’t panic. Here’s what you can do:
- Look for any errors. You’ve saved all your bills and EOBs, right? Good — you’ll need them to reference. Go through bills and corresponding EOBs with a sharp eye, looking for any duplicate charges for tests or procedures, or charges for medication you never received. If you think there are any errors on your bill, contact your provider’s office or your health insurance company.
- Try to negotiate the amount. If everything on the bill is correct, you may have luck in reducing the amount you owe by contacting the billing provider and asking them to lower their charge to match your in-network rate. Even if the provider is unable to do that, they may offer a small discount to help lower the overall cost.
- File an appeal. If you're a Wellmark member, your EOB and Coverage Manual explain your appeal rights and timeframe allowed for the appeal. Be sure to inform the billing provider that you’re appealing the insurer's payment amount, so they don’t automatically send it to debt collectors.
- Get outside help. Surprise bills can cause a lot of financial anxiety and stress — and can even negatively affect your health External Site. If your bill is correct and your provider or insurer won’t budge on the amount, you can look into patient hardship programs or payment plans to help reduce the burden slightly. These programs often have zero percent interest for a set amount of time, which can help you make payments without interest piling up. If you don’t know where to find such a program, contact the Patient Advocate Foundation External Site, which is a nonprofit group that helps people deal with unaffordable medical bills.
The bottom line
Previously, only 32 states and the District of Columbia External Site had varying levels of protection against balance billing. The recently passed No Surprises Act, which goes into effect starting in January 2022, will help protect patients nationwide from surprise out-of-network bills for emergency treatment and from surprise bills for non-emergency treatment received from out-of-network providers at in-network hospitals.
However, it’s still important for you to know how to avoid surprise bills and know what to do when they do happen, even after the new law goes into effect. If you have a Wellmark insurance plan, signing up for myWellmark is the best way for you to keep track of your claims, know what’s covered and not covered, and estimate costs for common procedures. If you’re not signed up, it’s free! Just go to myWellmark.com Opens New Window and get started today.