Rx for Surprise Medical Bills?

Rx for Surprise Medical Bills?

By Mary Johnson, editor

After 44-year old Drew Calver had a heart attack last year, his health plan paid nearly $56,000 for a four-day emergency stay in a hospital that was not in his insurance plan’s network.  The hospital then charged Calver another $109,000 — a bill for the balance, which is the difference between what the hospital and his insurer thought his care was worth.  Calver’s bill was reduced to $332, but only after Kaiser Health News and National Public Radio recently published his story.

Surprise bills like Calver’s can occur almost any time to any of us — including Medicare beneficiaries.  Often, the surprise bill is nothing more than a simple billing error when the provider doesn’t have correct billing information, such as your Medicare number, Medicare Advantage or Medigap insurance info.  (Stay calm and call your provider.)

Surprise balance billing, on the other hand, is no mistake.  It happens after you’ve satisfied your deductible, co-insurance or co-payment, and your insurance company (such as a Medicare Advantage plan insurer) pays everything that it’s obligated to pay.  However, if there’s still a balance owed, the bill gets sent to you.

Surprise balance billing is especially a problem for Medicare beneficiaries who unknowingly get care from a doctor that isn’t part of their health insurance plan’s provider network, or who doesn’t accept Medicare’s payment as payment in full.  This happens all too frequently, even to people who have carefully selected in-network providers and hospitals for their care.  Among the worst offenders are the doctors we don’t tend to see or interact with, including anesthesiologists in surgery, pathologists, radiologists (who interpret X-rays and scans), and those providing ambulance services.

The problem is so common, and frustration over exorbitant prices for medical treatment so great, that a bipartisan group of Senators has proposed legislation to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks.  The proposal targets three top concerns:

  1. Treatment for an emergency by a doctor who is not part of the patient’s insurance network, at a hospital that is also outside the network. Patients would be required to pay the out-of-pocket amount required by their insurance plan.  The hospital or doctor could not bill the patient for the remainder.
  2. Treatments by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network. Patients would pay only what is required by their plans.
  3. Notification of emergency patients, once stabilized, that they are receiving out-of-network care and could run up excess charges.

While legislation has not yet been introduced, TSCL supports this common-sense proposal, and plans to endorse legislation once introduced next year.  Have you been affected by surprise medical bills?  If so we want to hear from you!  Send us your story or comments at: www.SeniorsLeague.org.


Sources: “Surprise Medical Bills May Lie in Stitching up Federal Law,” Kaiser Health News, September 24, 2018.  “Senators Unveil Legislation to Protect Patients Against Surprise Medical Bills,” Rachel Bluth, Kaiser Health News, September 19, 2018.