This article defines “surprise billing”, offers scenarios where a surprise bill may occur, and also provides brief information on the No Surprise Act.
What is “surprise billing”?
Specific to healthcare, a surprise bill refers to a “balanced bill” where a provider bills you, the patient, for the difference between their charge and the amount paid by your health plan. A surprise bill is usually the result of an out-of-network charge. When a cost is in-network, the provider and the insurance plan have a previously agreed-upon arrangement for what the provider will charge and what the insurance will pay. With an out-of-network cost, no such agreement exists: the provider will charge what they feel is appropriate, and the insurer will pay what they feel the service is worth. When these two figures do not align (usually with the provider asking for more than the insurer is willing to pay), the patient is billed by the provider for the balance difference. It will then become an unexpected or “surprise” bill to you, the patient.
In what scenarios might you receive a surprise bill?
There are numerous situations that might lead to a surprise bill, but a majority of these are related to emergency (ER) services. In the ER, providers often have to act quickly, and they may be using contracted help—such as an X-ray that is read by an outsider, third-party source. In another scenario, you might have a blood draw where the phlebotomist is in-network, but the lab result is farmed out to a service that happens to be out-of-network. Another common scenario may involve a procedure where a specialized provider involved in the procedure (like an anesthesiologist) may be out-of-network, even if the procedure facility and the primary physician/surgeon is in-network.
What can I do if I get a surprise bill?
Recently passed legislation protects patients from surprise billing. The No Surprise Act offers consumers billing protections when getting emergency or non-emergency care from out-of-network providers at in-network facilities. It also provides out-of-network protection from air ambulance services.
The No Surprises Act, however, does not protect you if your provider (ER, hospital clinic, or other facility) is out-of-network.
What can BioMatrix do to help with a surprise bill?
If you think you are a victim of a surprise bill, we can determine if the bill in question falls under the patient protections of the No Surprise Act. We can also help guide you to a resolution.
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