An Unwelcome Surprise: How to Handle Unexpected Medical Bills

In the 2000s, health plans began using networks to control costs and ensure appropriate care.  As time went on, networks became "a tool for narrowing access," says Kirch. Doctors and other providers also began choosing which plans they wanted to work with, making the health care system even harder to navigate.

"Patients were left in … the middle of the game between insurance plans and what they paid and providers and whether or not they were in network," says Kirch. "They left it to the patients and families to figure out."

A 2020 survey found that:

• 1 in 5 insured adults had an unexpected medical bill from an out-of-network provider.
• 18% of ER visits resulted in at least one surprise bill.
• Two-thirds of adults worried about affording unexpected medical bills for themselves and their family.

Why Would I Get A Surprise Bill?

You could be hit with an unexpected bill if:

A provider is out of network. For instance, maybe your surgeon is in your network but the anesthesiologist who sedates you for your surgery isn't.

A facility is out of network. In an emergency, you might not have time to find and get to an in-network hospital.

A billing error. Your bill could be wrong for any number of reasons, including a misspelling of your name, incorrect health insurance information, missed details from your visit, or a mistake in coding.

Marisa S., who lives in South Florida, gets health insurance through the hospital where she works. She has one copay, and all other costs are covered at 100%. No deductible applies. But when an illness in May led to a three-night hospital stay, she was shocked to be billed over $600 because the doctor who treated her was considered "out of network."

Marisa called her health plan, who told her to call the hospital. The hospital billing office told her to call her health plan. The doctor's office assured her they would fix the mistake. Four months later, "it's still on my claims as a balance that says I owe that money," she says.

What's the No Surprises Act?

In 2022, the No Surprises Act, which can protect you from surprise medical bills, went into effect. It can help limit your out-of-pocket costs if:

• You get emergency care from an out-of-network doctor or facility and didn't have prior authorization from your health plan.
• Your health plan wants to charge you out-of-network copays and coinsurance in an emergency situation.
• You see an out-of-network doctor in an in-network hospital.

If you don't have health insurance, the No Surprises Act can still help you. If you get a "good faith" estimate of the cost of your upcoming care, then receive a bill that's $400 or more over that estimate, the No Surprises Act allows you to dispute the bill.

You may already be protected from surprise billing if you have any of these health plans:

• Medicaid
• Medicare
• Indian Health Service
• Veterans Affairs Health Care
• TRICARE

Who Isn't Helped by the No Surprises Act?

This law can't protect you if you have:

• A short-term, limited health plan
• A stand-alone benefits plan like dental or vision
• A retiree-only plan
• An account-based group health plan (for example, your workplace reimburses you for healthcare expenses)

Some doctors or medical centers may ask you to sign a "notice and consent" form when you're getting nonemergency care. If you do, you agree to give up your surprise billing protections and pay higher out-of-pocket costs for your care.

You aren't legally obligated to sign this form. If you don't, the doctor or facility may not give you nonemergency care. You'll have to find an in-network provider instead.

If they do still give you care, the No Surprises Act can still protect you.

Surprise Consequences of the No Surprises Act 

You're less likely to get a surprise bill now than you were a few years ago. Today, "it's more common that clinicians are fighting with insurance companies," says Kirch.

If a provider is out of network and they don't want to accept the payment that your health plan offers, they can go through what's called an independent arbitration process (IDR). This gives both parties a chance to agree on a fee.

"What we're seeing is that the vast majority of those disputes are started by the providers, saying, 'Hey, we're not being paid enough. We think the reimbursement should be higher,' " says Hargraves. "And in most cases, the ruling is in favor of [them.]"

While you won't be involved in this process, it quietly adds to the rising cost of healthcare. 

"If [health plans] aren't making money through network restrictions and balance billing, they're going to find another way to do it," says Kirch.

What to Do if You Get a Surprise Bill

Here's what you can do if you're hit with unexpected charges:

Don't lose hope

First, try to understand the bill. This can be tricky because of the different jargon that health plans use.

"Copay, coinsurance, deductible, and all of those things are like Monopoly math when you're trying to figure out what your coverage paid for," says Kirch. "But if you give up and say, 'Oh, I'll just pay it. It's not worth the time,' that can be a lot of money."

Call your health plan

If you're insured, call the customer service number on the back of your insurance card. Ask questions like "Why did I receive this bill?" and "Why is this service not covered?" Have the representative walk you through the amount that your plan will pay and your responsibility as the patient. Take notes in case you need to refer to them later.

Contact the provider

Call your doctor's office or the facility's billing office and have them explain each line item of your charges. Check for any billing mistakes. Although they're common, one survey found that when you reach out about an error, it's corrected more than 73% of the time.

Get your employer involved

If you get insurance through your workplace, your human resources department may be able to help. For example, when Marisa was incorrectly billed twice for her annual exam, she filed an appeal with her insurer. When it was denied, "I got HR involved, and HR was like, 'No, she's right. Fix it,' " she says.

Bring up the No Surprises Act

For instance, if you're being billed because the ER you went to for an emergency was out of network with your plan, remind the hospital billing office and your insurer that you're protected by the No Surprises Act.

You can also call the No Surprises Help Desk at 800-985-3059. It's open seven days a week, and you can get assistance in over 350 different languages. For no cost, a trained professional can help you submit a complaint or connect you to more resources if your situation isn't covered by the No Surprises Act.

What Else Needs to Change? 

Some experts view the No Surprises Act as a Band-Aid on a healthcare system that needs far more serious care.

There's still "a lot of price variation and not a lot of transparency," says Hargraves.

If you ask your doctor, "How much is this going to cost?" they likely can't answer that question. "But the same service shouldn't cost tenfold depending on who you're seeing or where you're seeing them," says Hargraves. "An X-ray is an X-ray."

Understanding how much your medical care costs could help you make informed decisions, versus only knowing how much a procedure or doctor's visit costs after you get a bill.

"Affordability in healthcare is an uncomfortable conversation," says Hargraves. "If a doctor orders a test or a scan or a procedure, rarely do you feel comfortable asking, 'Well, how much is that going to cost? it really necessary?'"

Although it's common to talk about the importance of good physical and mental health, "financial health is an essential part that's never brought up, and it's integrated into every way that you make decisions about treatment, care, and longevity," says Kirch.

"If you get hurt in an accident,  it's not like you can say, "Well, I have a broken leg, but I'm going to hold up till next month because I'll have more money then,'" says Chris. "It's not like you have a choice."

Until the health care system improves, you don't need to struggle to make sense of it by yourself. "Find somebody who can navigate [it] with you," says Marisa.