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Unpacking Surprising Medical Bills and Statements

Updated: Aug 18, 2023

Receiving a medical bill or statement can be overwhelming – especially when it is unexpected. You may not understand why you are receiving a bill to begin with let alone the charges, what services are included, or why it’s more expensive when you are aware you would incur a cost sharing balance. To help you make sense of a surprise medical bill and statement, let’s break down what you need to know.

Understanding Your Patient Statement

Your patient statement is a summary of all the services you received from your doctor or hospital visit. It includes a list of the treatments and medications that were administered to you during your visit as well as any additional fees for lab tests, supplies or equipment used in your care. These services may have been provided by multiple providers and billed under a single master bill or sent individually resulting in multiple bills. Some providers send a summary total while others give an itemized breakdown. This can include how much each service costs and any insurance coverage applied towards the total amount due. There are several key elements you should be aware of. First, look at the payment due date on your statement as this will determine when payment is due on the balance owed. Next, look for any fees or charges that have been added to your bill since the last one was issued. These additional fees could include late fees or interest charges. One of the documents you probably signed when you were a new patient is the healthcare’s financial policy that lists the additional fees and under what circumstances you would incur these on your account. Lastly, make sure to check for any discrepancies in billing codes or rates as this could indicate potential errors in billing practices by the health care provider.

It can feel like you are bombarded with bills. A typical provider sends a minimum of three billing statements. Don’t ignore them because your patient statement is intended to give you an understanding of the services rendered and charges incurred during your visit.

Understanding Surprise Medical Bills

Surprise medical bills are unexpected charges that are not covered by insurance like copayments, coinsurance, deductibles, out-of-network care providers, and other fees charged by certain specialists. An out of network balance happens when you receive services or treatments from a provider who is not contracted with your insurance plan. In some cases, surprise bills may cost hundreds or even thousands of dollars depending on the services provided. They are usually much higher than what was initially expected, leaving you feeling confused and frustrated. The amount owed will depend on the specific procedure performed as well as any additional fees associated with it such as anesthesiologist fees or laboratory tests ordered by a specialist. It's important to review your patient statement carefully to ensure that all charges are accurate and correspond to the services you received and that no surprises have been added on without your knowledge. It is important to understand that surprise medical bills are not uncommon and can happen even if you have insurance coverage.

Minor to major medical billing errors happen due to human error, medical coding changes, coding modifiers (provides additional explanation for a service, supply or procedure) and insurance payment rule or coverage changes. Other causes affecting the accuracy of a medical bill could include antiquated technology and inaccurate claims assessment affecting the amount of a patient’s claim payment.

At the federal level, the No Surprises Act went into effect in 2022 for the majority of patients enrolled in an individual or group health insurance policy. It provides additional patient protection beyond state laws for certain situations that result in a surprise medical bill balance. Such scenarios include an emergency room service provided by an out of network provider or facility without prior authorization, out of network supplemental care by out of network providers working in an in-network facility and air ambulance services from an out of network provider.

Medical billing practices vary from state to state but most states do have laws in place to protect consumers from surprise medical bills and unreasonable fees. In Illinois, House Bill 4703 expands upon the protections of the No Surprises Act by extending its prohibition against balance billing to all non-participating facility-based physicians providing services at an in-network hospital or other facility, not just radiology, anesthesiology, pathology, neonatology and emergency physician services covered under the federal law. Additionally, it requires health care facilities to provide certain information about network providers on their websites and other materials.

While the law may appear cut and dried, there are exceptions to be aware of which could leave you with a balance. Illinois protections are only available if you are enrolled in a state regulated health insurance plan and the provider is based within an in-network facility. If either of these two criteria is not met, you may be subject to receiving an unexpected bill due to charges incurred outside your network. Keep in mind that any intentional selection of a nonaffiliated health care professional could result in additional charges which are not protected under existing regulation.

As a patient and consumer of medical services, it's important to familiarize yourself with laws such as these so that you know your rights when it comes to negotiating with providers for lower rates or appealing disputed charges. Additionally, many health insurers offer resources for patients who need assistance understanding their medical bills and navigating their insurance coverage options. Be sure to research which providers are within your approved insurance network so that you can avoid any unwelcome financial surprises.

Receiving an unexpected medical bill is never pleasant but if you take time to review your patient statement line by line, you can better understand why the bill was higher than expected and take steps to address it if necessary. If you receive a bill with one total, you have the right to request an itemized bill and you should. Knowing your rights as a consumer is key when dealing with surprise medical bills.

To learn more about the No Surprises Act, visit the Centers for Medicare & Medicaid Services site for a brief fact sheet.

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