Surprise Medical Bills
Have you ever received a medical bill that came as a total surprise? You are not a alone. A 2016 Kaiser Family Foundation survey found that among insured, non-elderly adults struggling with medical debt, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.
The term “surprise medical bill” is commonly used to describe charges when an insured individual inadvertently receives care from an out-of-network provider. Surprise medical bills might occur when patients receive planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patients’ care are not in the same network. In these non-emergency situations, the in-network provider or facility generally arranges for the other treating providers, not the patients. So when patients receive the bill, they are surprised because they do not recognize the name of the provider and did not know in advance that an additional out-of-network charge was coming.
For patients with private insurance, their insurers negotiate contracts to reduce the cost of certain treatments, procedures or surgeries. Because out-of-network providers have no such contractual obligation, patients receiving care from a provider not in their network can be liable for the additional cost of an out-of-network provider.
House Bill 152, now making its way through the Montana Legislature, revises health care provider network disclosures, so that patients can get estimates of charges for their planned treatment and can opt out of having a non-network provider as part of their care team. Also, with some caveats, the patient who has done due diligence and investigated costs is protected from surprise charges by HB152. A provider who is not in the provider network of a patient’s insurer may bill the patient only the amount the patient would have paid for using an in-network provider.
Montana has had a law on the books since 2009 that requires all health care providers to provide estimates of charges if the care will cost more than $500 and if the patient asks for the estimate. HB152 adds to these consumer protections by requiring that when a patient asks for an estimate of charges, certain care providers (physicians, advanced practice registered nurses or physician assistants) must disclose the following information:
- What insurance networks the health care provider is in.
- What additional members will be on the health care team for the services.
- Whether a member of the health care team will be billing the patient separately for services.
- Whether the patient needs to ask for charge estimates from other providers.
- Whether the members of the health care team are in the patients’ health insurance network.
The good news about HB152 is that Montana medical organizations and private insurers have weighed into the language and have agreed to provide the transparency that the bill requires. Many health care providers and hospitals in Montana already provide this information for patients. Both hospitals and insurance companies have online tools with network information and costs of commonly used procedures and medical services. But this information is only useful if patients take advantage of the opportunity to get estimates of charges prior to receiving service and find out whether their providers are in or out of their insurance networks.