Surprise Medical Bills
Note: This information should not be interpreted as legal advice.
A Consumer Guide to Surprise Medical Bills
Sometimes, people get care from a health care provider such as a doctor, anesthesiologist, or radiologist, who is not in their health insurance plan’s network even though the care they received was at an in-network facility. This can happen if you have surgery at an in-network facility and it turns out that someone on the surgical team, like the anesthesiologist or surgical assistant, is not. It can also happen if you go to an emergency room that is in your network and the doctor who takes care of you does not accept your insurance. After the services are received, you might get a bill in the mail saying you owe the out-of-network provider money. This is called a “balance bill”.
What is balance billing?
A balance bill, or surprise medical bill, charges you for the difference between what your insurance pays to the out-of-network provider and what the provider charges for the services. When the provider is in-network, you only have to pay what is negotiated with your health plan—usually a copay or a percentage of the charges billed. However, if the provider is unexpectedly out-of-network, you may be asked for much larger sums. Colorado has limited protections for the consumer against balance billing.
Division of Insurance (DOI) regulated health insurance plans—those that say “DOI” on the health insurance cards—are required to hold patients harmless when treated by out-of-network providers at an in-network facility, or in emergency situations. Specifically, patients can only be charged at the in-network rate. (The Colorado Revised Statutes where these protections can be found are C.R.S. 10-16-704 sections 3 and 5.5) That means that if you would have owed a $50 copay for the services in-network, then you don’t owe more than $50 if your provider is unexpectedly out-of-network.
As of January 1st 2020, Colorado law prohibits providers from sending these balance bills to consumers (C.R.S 12-30-113).
If you have a Colorado regulated plan and receive a surprise balance bill, contact your insurance carrier and file a complaint with the Division of Insurance.
Similar protections to prevent consumers receiving these surprise bills will apply to insurance plans not regulated by the Colorado DOI in 2022.
While those protections are not yet in affect, below is some advice to help you avoid a surprise bill situation.
Be Prepared to Avoid Balance Billing
Call your insurance company’s member benefits number or help line before making an appointment for any sort of procedure. Ask about your plan’s coverage and network. Also ask if the services you need should be free. Preventative healthcare services should have no copay.
Confirm with your doctors that they are in-network, and that other involved providers will also be in-network. You can also double-check any expected charges with your provider before going to your appointment.
Ask for explanations regarding services and procedures your doctors prescribe. Make sure that you understand why each is necessary, and what the associated costs are.
Remember—it’s always ok to ask questions!
Tips on reading and understanding your medical bills
Open and review all medical bills immediately and use these questions as a guide:
- Is it a bill or an explanation of benefits? (an explanation of benefits will say “this is not a bill” somewhere visible)
- Who sent the bill?
- Is the bill the expected amount? Is your insurance plan covering their share/has their contribution to the bill been accounted for?
- Is the bill overdue? Did a law firm or debt collection company send it?
- What is the bill for? (If you are confused, call the entity billing you to ask for an explanation of the charge)
- What are the details of the bill? You are entitled to an itemized bill if you ask for it; if you are unable to get one, file a complaint with the Colorado Division of Insurance here.
- Do the billed services match the services you received?
What do you do if you find an error or if you think you have been mistakenly balance billed?
Before you pay:
Step 1: Contact your insurer about the bill
Ask for clarification. Make sure that your insurer received a claim for the services for which you’re being billed. Ask if you are being held responsible for part of the billed amount, or for the entire bill.
Step 2: File a complaint with your insurer aka an ‘internal appeal’
If your insurer does not agree to pay the claim, and you think it should be covered, you have the right to appeal within 180 days of your denied claim. An appeal means that you are asking your insurer to reconsider their decision not to pay. Keep in mind that if your bill is a true balance bill, the insurance company may not have been asked to pay and you can send them a copy to take care of it for you.
Important Reminder: document all phone calls and keep copies of all paperwork.
If the problem is not resolved:
Step 3: File a complaint to the CO Department of Insurance
Through an external, or third-party appeal, the Department of Insurance will review your claim within 60 days of the denied internal appeal
Learn more about the appeals process and your rights in Colorado here.
Step 4: Tell your story to the Colorado Attorney General’s office
Call 800-222-4444 and let them know that you have experienced balance billing.
If you have deliberately chosen to see an out-of-network provider, when your insurer offers adequate in-network care, you may be held responsible for any additional costs. If you need information on financial assistance, and payment programs to help you pay your hospital medical bill go here.
Has this happened to you?
We want to hear about it! CCHI is working to improve consumer protections against balance billing. Share your story with us here or contact CCHI with questions.
We can help! CCHI’s Consumer Assistance Program can help you navigate balance billing issues. Contact us at firstname.lastname@example.org.
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