Published September 23, 2019|4 min read
Almost half of hospital inpatient admissions and emergency department visits result in an out-of-network bill, new research finds.
The average liability of these bills more than doubled from 2010 to 2016, according to a study published in JAMA Internal Medicine, a medical journal.
The study analyzed a database including health insurance claims for people from all 50 states, all covered by the same large insurer. The analysis looked at 5.5 million inpatient admissions and 13.6 million emergency department visits at in-network hospitals.
From 2010 to 2016, the percentage of emergency department visits with an out-of-network bills increased from 32.3% to 42.8% and the average liability for these bills went from $228 to $628. For inpatient admissions, the percentage of out-of-network bills rose from 26.3% to 42% and the average cost went from $804 to $2,040.
These are often referred to as "surprise bills" because people assume they won't face as big of an out-of-pocket cost at an in-network hospital. But that's not always the case.
When health care providers agree to be part of an insurer's network, they usually agree to accept a set amount of payment from the insurer in exchange for their services. Providers who are not in this network can bill patients directly.
Many insurers cover some out-of-network expenses, but patients are responsible for the balance — that's why out-of-network bills are also referred to as balance bills. (Learn how to read a hospital bill.)
Avoiding such bills might sound like a matter of only seeing in-network health providers. But especially in a hospital setting, patients don't know which doctors treating them are in-network.
So even if you visit an in-network hospital, you could end up getting treated by an out-of-network doctor and receive a surprise bill.
Surprise bills are particularly common in emergency situations, when you might not be in a position to choose your provider or facility (85.6% of emergency room visits involving an ambulance led to an out-of-network bill). But even when you schedule a procedure specifically in an in-network facility, in many cases, out-of-network providers, particularly anesthesiologists, might still be out-of-network.
Congress seemed like it was about to pass legislation preventing doctors from sending surprise bills to patients this year. But it's looking less likely after a bout of intense lobbying, The New York Times reported.
For now, you may have protection from out-of-network bills depending where you live. Twenty-eight states have passed protections against balance billing, according to research from the Commonwealth Fund, a health care research foundation.
For example, New York requires insurers to hold their members harmless for any charges above in-network prices and bars out-of-network providers from billing people for amounts above those in-network prices. This leaves providers and insurers, not patients, to deal with any balance above the in-network price.
While you can't always control who is providing a given medical service, it's best to try to get an idea beforehand.
"Before you get your service, especially if it's an elective service, I would insist upon the hospital providing you with the list of providers who are expected to provide services for you and ask about their network status," said Maanasa Kona, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.
If there are out-of-network providers, you can ask the hospital or facility if they can swap in an in-network provider if possible. They may or may not be able to accommodate you, but it's better to know ahead of time either way.
If you do receive a surprise bill, contact the provider who sent it. Sometimes bills are sent in error. If not, many providers are often willing to negotiate on prices or set up payment plans to help spread out the financial blow and keep you from falling into medical debt.
You can also reach out to your state insurance department, especially if you live in one of the 28 states offering some form of surprise billing protection.
"You should definitely contact your state department of insurance whenever you get a bill and you feel like you should not be paying it," Kona said.
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