A Surprise Medical Bill: When You May Not Owe It

Start with the type of care

A surprise bill is a charge you did not expect because it came from a provider you did not choose or could not avoid. Federal surprise billing protections can apply in specific situations. The No Surprises Act, the federal law that limits certain surprise bills, covers many emergency services, certain non-emergency services from out-of-network providers (providers who do not have a contract with your insurance plan) at covered in-network facilities, and out-of-network air ambulance services. It does not cover every high medical bill.

Start by looking at what kind of care created the bill. Emergency care, anesthesia, radiology, lab work, and hospital-based services are worth checking carefully, because you may not have chosen the out-of-network provider who treated you.

Check these documents first

Gathering the right paperwork before you call or write anyone makes every later step faster. Pull together the following documents so you can compare them side by side.

Collect each of these that applies to your bill:

• The provider bill showing the amount charged
• The explanation of benefits from your insurance company
• The date of service and facility name
• The provider name listed on the bill
• Any prior authorization or referral paperwork
• Any notice or consent form signed before care
• Any good faith estimate if you were uninsured or self-pay

Compare the bill to the explanation of benefits

The bill and the explanation of benefits are two different documents, and they do not always agree. The bill comes from the provider or facility, while the explanation of benefits comes from your insurance company. The explanation of benefits shows what was billed, what your insurer allowed, what your insurer paid, and what you may owe.

Compare the two carefully. If the provider bill asks for more than the patient responsibility shown on your explanation of benefits, write that difference down. If the bill says out-of-network (meaning the provider has no contract with your plan, as opposed to in-network providers who do), compare that against the facility and the type of service you received.

Look for balance billing language

Balance billing means the provider bills you for the gap between the provider charge and the amount your insurance paid or allowed. Federal surprise billing protections can limit balance billing in covered situations, so it helps to know when a bill is doing this.

A bill may describe that gap in several ways, so read the wording closely. Look for phrases such as out-of-network charge, remaining balance, non-participating provider, patient balance, or not covered by plan. Save the page that shows the wording, since it may matter later.

Check whether a consent form was used

Some out-of-network services may involve a notice and consent form, which is a document that tells you a provider is out-of-network and asks you to agree to be billed accordingly. That form can affect whether federal protections apply, so save a copy of anything you signed before the visit, procedure, or admission. If the paperwork is missing, ask the provider billing office for a copy of any notice and consent form tied to your date of service.

Call the provider billing office and your insurance company separately, and ask narrow questions of each. Keep a call log with the date, time, phone number, representative name, and what was said.

When you reach the provider billing office, ask:

• Which provider created this charge?
• Was this provider out-of-network on the date of service?
• Was this service emergency care or a hospital-based service?
• Was a No Surprises Act notice or consent form used?
• Can you place the account on hold while this is reviewed?

When you reach your insurance company, ask:

• Was this processed as in-network or out-of-network?
• Was this claim reviewed under federal surprise billing protections?
• Is there an internal appeal option for this claim?

Read the patient responsibility on the explanation of benefits

The explanation of benefits lists a patient responsibility figure, which is the amount your insurer says you actually owe after it processed the claim. That number is the one to trust when you compare it against the provider bill.

As you read the explanation of benefits, confirm each of these:

• Whether the claim was processed as in-network or out-of-network
• Whether the claim was reviewed under federal surprise billing protections
• Whether there is an internal appeal option for this claim

Where does a written dispute or appeal get sent?

If you were uninsured or self-pay, start with the good faith estimate, which is the written cost estimate a provider gives you before scheduled care. Uninsured and self-pay patients may have a right to a good faith estimate in many scheduled-care situations. If the final bill from a provider is at least $400 more than that provider's good faith estimate, CMS says you may qualify for the patient-provider dispute resolution process, a review process for resolving that gap. This process has its own rules, so save the estimate, the final bill, and the date printed on the bill.

Do not rely on one phone call to settle the matter. A phone call can help you identify the issue, but the dispute or appeal usually needs written follow-up. Ask where written disputes go, what documents are required, and how your account will be paused while it is reviewed.