Surprise Billing, Part I

Going to the hospital can be an extremely stressful experience. Receiving surprise bills in the weeks, months or even years after said hospital stay is even more stressful. For those of us who see doctors regularly and often have hospital stays interspersed throughout the year, it can be overwhelming.

First, let’s define surprise billing. Broadly speaking, surprise billing (SB) occurs when an insured patient receives care from a provider that is out of the individual’s insurance network, usually without their knowledge. This bill typically arrives months or sometimes years after the treatment happens. Oftentimes, this arrival is also accompanied by a referral to a collections agency. Sometimes, the patient gets an Explanation of Benefits (EOB) from their insurance company before or after the arrival of the surprise bill.

Second, let’s define an EOB, which is the document received from the insurance company that the medical provider sent the bill to for payment. That document should provide enough of an explanation for the patient to understand what was billed, what was paid, the remaining patient responsibility and why. This document usually contains dates of service, brief descriptions and, typically, CPT codes.

Third, let’s define CPT codes:

The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

https://en.wikipedia.org/wiki/Current_Procedural_Terminology

When a patient receives the bill, months and months later, it is often incomprehensible and the patient is still dealing with the aftermath of whatever illness gave rise to the medical treatment. Many times the EOBs are late in coming and they often don’t arrive in chronological order. Many patients don’t understand that they will receive bills from a variety of entities for a hospital stay, not just the hospital.

What is the solution?

When an educated patient/consumer obtains the information applicable to them, their State, their insurance company, and then applies that knowledge, the stress of those surprise bills can be lessened. Knowledgeable and educated patients/consumers applying their rights and ensuring that entities are kept honest is so key. Then, educating others so that the predatory practices of some clinics are stopped.

Stay tuned for Part II, where I’ll outline some tips and tricks that has helped me. I’ve not paid one surprise bill and I’ll explain how and why.