Reasons Why You Might Get A Surprise Hospital Bill

Going to the hospital can provide much needed relief from whatever illness or issue you are suffering from. However, when you get the bill you might find some surprising costs. It's important to understand your medical bill and how to avoid any surprise charges.
By Andrew Glass
Updated Nov 4, 2020
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A visit to the hospital often leaves you feeling better, but an unexpected bill in the mail a few weeks after your release can spoil that good feeling. Fully 57% of Americans have encountered this unpleasant experience, according to an AmeriSpeak® survey from NORC at the University of Chicago. Some of those bills were simply larger than anticipated while others landed in the mailbox to the complete surprise of their recipients. More than half of these bills were for physician services or laboratory tests while the rest came primarily from imaging, prescription drugs, and healthcare facility charges.

Unfortunately, unexpected medical bills are showing up more and more often. Dr. Eric Sun, a researcher at Stanford University, looked into the question of surprise bills. He found that 32% of emergency room visitors in 2010 got a surprise medical bill, but in 2016, that number rose to 43%. The number of bills wasn't the only thing to go up. Average costs did, too, rising from $220 to $628. Dr. Sun also found that inpatients are getting nasty surprises, too. In 2010, 26% of them received a surprise medical bill, a number that rose to 42% in 2016. Costs from there ramped up from $804 to a whopping $2,040. 

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Why does this happen?

When you have insurance, shouldn't your provider take care of everything? What are the reasons why you might a surprise hospital bill? Several factors go into medical billing, but here are seven common reasons you could accrue an unexpected cost from a hospital visit or stay.

1. The service you received wasn't covered by your health plan.

Your health insurance provider may not cover all the services your doctor or nurse practitioner recommends. You might think it should, but it doesn't. Frequently, infertility treatments, dental surgeries, and eye exams don't get covered. Always ask your doctor to verify that your insurance will cover a specialist visit, test, treatment, or medication that she or he is recommending. If not, inquire about an alternative that might be covered or find out if you can hold off on that service while you put some money away to pay for it. Asking a few questions now can save you big in the long term. 

2. You may not have met your deductible yet.

Insurance providers expect you to pay your part, known as the deductible, before they will meet their part. The average deductible for a single person is about $1,500, and for a family, it runs closer to $2,800. Your specific deductible will vary, though, depending on your company and the policy you hold. If you have not yet met this year's deductible, you'll have to do that before your insurance will kick in.

3. The provider might have been out of your network.

Visiting an out-of-network provider is the quickest way to rack up medical charges that you'll be responsible for covering. If you go to an out-of-network provider for anything other than emergency room treatment, the bill is all yours to pay out of pocket. In some cases, not even all emergency room treatment is covered. And if your in-network doctor recommends an out-of-network specialist, you'll get billed for visiting that provider. Always check with your insurance company to find out of who is in your provider's network and who isn't before you schedule an appointment with any medical practitioner.

4. Some staff at the in-network hospital don't have a contract with your health insurance provider.

Let's say you visit an in-network hospital, but the doctor who sees you doesn't have a contract with your insurance company. You'll probably be forced to pay out of pocket for that doctor's portion of your treatment. Before you see any specialist, therefore, tell your primary care doctor in advance that you only want to work with providers in your network. And if something like this happens to you, call your insurance company and appeal. You likely don't have any legal grounds for your request, but you can ask for the company's understanding and assistance, and you just might get it.

5. Your ambulance company does not contract with your insurance company.

So you rode to the hospital in an ambulance or took a medical chopper to get there? Will your transportation be covered by your insurance company? It might seem like it should be since the ambulance is connected to the hospital, but that's not always how it works. Some health insurance plans cover ambulance rides, and some don't. Since you probably aren't calling around for the best rates if you need emergency medical transport, 21 states have decided it's illegal for insurance not to cover an ambulance ride, but the other states have not. Ambulance rides can run several thousand dollars.

6. You get billed by a contractor working in an emergency room.

The doctor who treats you at an emergency room may not be employed by the attached hospital. That means that your insurance could cover your emergency room bill but not the costs of the doctor who treated you at that emergency room. Yes, that really happens. In fact, it occurs so often that the New York Times did a story about this problem, which said, "22 percent of the time, patients who went to a hospital covered by their plan still received a bill from a doctor." Some states have passed legislation against this practice, but if you live in a state that permits it, your only option is to appeal to your insurance company and to the emergency room. One or the other may help you cover some of the bill.

7. Your insurance company made a mistake.

It's possible -- and the outcome we all hope for -- that your insurance company is billing you due to an error. The algorithms, bots, and people employed at insurance company can malfunction, leaving you with a bill you don't actually owe. While the charges probably are yours to cover, it's always a good idea to call your health services provider and your insurance company before you write a check. Sometimes, it's just a simple error that needs fixing, and you can get a much smaller bill, or none at all, in place of the heart-stopping one you hold in your hand.

While insurance makes many medical treatments possible, it doesn't cover everything. Unexpected hospital bills come more often than many people think. But with a little planning ahead, you can limit or even eliminate the high cost of surprise hospital bills at your home. 

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