Surprise Medical Bills
Balance billing – or a surprise medical bill – happens when you get a bill from a doctor, hospital, or other health care provider who isn’t part of your health plan’s network. Often, consumers didn’t know they were getting care from out-of-network providers.
For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the $600 that the health plan didn’t pay, as well as any copays, deductibles, and coinsurance.
I got a surprise bill. What can I do about it?
- Call the doctor or provider that sent the bill and discuss your concerns. In most cases, Texas law requires providers to provide an itemized bill on request, so review the charges carefully. Some providers might accept a lower payment. You can compare the amount you were charged to the average market price using TDI’s Health Insurance Reimbursement Rates Consumer Information Guide or websites such as NewChoicehealth.com, FairHealthConsumer.org, and TxPricePoint.org.
- Call TDI’s Consumer Help Line at 1-800-252-3439 to discuss your options. There are two main ways TDI can help:
- Mediation: TDI staff can work with you and your health-care provider on an agreement. Texas law allows many consumers to seek mediation for bills that exceed $500. TDI has helped 94 percent of consumers lower their bills in the first stage of the process.
- Complaints: We helped recover $490,518 for Texas consumers who filed complaints about balance billing in 2015.
How can I protect myself from surprise bill?
- For planned procedures, find out in advance whether your providers are contracted with your health plan. This is especially important in the case of facility-based providers, such as radiologists, anesthesiologists, pathologists, and neonatologists. Even if a hospital is in your health plan's network, some doctors who provide services there might not be.
- Call your health plan to make sure the services you will get are covered under your policy. If the services are not covered, you will have to pay the charges.
- Texas law gives patients the right to request estimates of charges. Doctors and other providers and health plans have 10 days to give you the estimates, so you won't be able to get them in cases of emergencies. Some providers and health plans also have cost information on their websites.
- Shop around. The Texas Department of Insurance’s Health Insurance Reimbursement Rates Consumer Information Guide lists average costs for common medical procedures for different regions in Texas. Websites – such as NewChoicehealth.com, FairHealthConsumer.org, and TxPricePoint.org – also can help you estimate the prices of various procedures.
- If there aren’t any contracted providers available, your health plan might be able to work out a discounted payment. You also might be able to ask your doctor or provider if they’ll accept payment options in advance. In some cases, the health plan may be required to make sure you aren’t balance billed.
Complain to the right agency.
If you believe you’ve been treated unfairly, file a complaint with the agency that regulates your provider or health plan.
- File complaints against doctors with the Texas Medical Board.
- File complaints against hospitals, ambulatory surgical centers, or other facilities with the Texas Department of State Health Services.
- File complaints against licensed health maintenance organizations and health insurance companies with the Texas Department of Insurance.
Get Help from TDI
For insurance questions or for help with an insurance-related complaint, call our Consumer Help Line at 1-800-252-3439 or visit our website. For more information about surprise billing, visit the Avoiding Surprise Bills and Handling Surprise Bills pages.
For more information contact:
Last updated: 05/10/2016