A surprise medical bill is a bill for medical services an individual thought would be covered by his/her health insurance. The issue of surprise medical bills is receiving more and more attention as the cost of healthcare in the United States continues to rise. According to a recent Kaiser Family Foundation poll, 89% of Americans are concerned about the increased amount individuals pay for health care. In this survey, concerns about surprise medical bills topped the list, beating out high premiums, high deductibles, and rising drug costs. I have been floored by the stories about surprise medical bills featured in Kaiser Health News’ Bill of the Month series. From a $17,850 bill for a urine drug test to a $109,000 bill for a hospitalization after a heart attack, these stories feature common scenarios when patients receive care unexpectedly from out-of-network healthcare providers/facilities. See Part 1 of “How to Avoid Surprise Medical Bills” for more information about out-of-network providers and what you can do to minimize your risk.
At the root of surprise medical bills is a refusal by your health insurance company to pay for a service you received. There are a variety of reasons why services are not covered by health insurance companies, many of which are related to policies listed in the summary of benefits most of us don’t bother to read. I’m certainly not blaming you, the consumer. The language in most insurance documents tends to be confusing and unclear. In my opinion, health insurance companies should do a much better job ensuring that enrollees understand their benefits. Share on X While we hold our collective breaths waiting for that to happen, please allow me to shed some light in hopes that you will avoid some common pitfalls.
A common health insurance policy that leads to unexpected medical bills involves uncovered services.
Uncovered Services
Don’t assume that because you have health insurance it will cover all of your healthcare costs. Share on XDepending on your health insurance policy, certain services may be completely excluded. Common services not covered by health insurance include treatment for infertility, travel vaccines, and cosmetic surgery. The good news is that you are unlikely to receive a surprise medical bill for these types of services, as the staff and providers working in the above-mentioned specialties do a very good job explaining their fees and the expectation that you will pay out-of-pocket. This information is typically shared during the first point of contact when you call to schedule an appointment. No surprises there.
Perhaps the most problematic surprise bills for uncovered services are for tests or procedures performed in connection with a preventive medical appointment. Preventive care is the medical care you receive to prevent illnesses or diseases and includes things like an annual check-up or health assessment, counseling about healthy habits, and certain screening tests. Under the Affordable Care Act, compliant health insurance plans are required to provide a number of preventive services free of charge. On occasion, an insurance company may incorrectly deny payment for one of these services.
When my teenager had her 17-year-old check up last year, she was asked to complete a questionnaire that screened for depression. Despite the fact that the American Academy of Pediatrics recommends annual screening for depression in adolescents ages 12 and over and the fact that depression screening is one of the 31 children’s preventive health services mandated by the ACA, we received a bill for $10 because it was not paid by our insurance company. In full transparency, I had not yet done my homework on this issue and because it was only $10, I paid the bill. This is a perfect example of the importance of clearly understanding your health insurance benefits and reading the small print. I could have appealed those charges. (For a list of preventive care benefits mandated by the ACA for adults, click here.)
While this was a case of an error on the part of the insurance company, there are other services that, when performed as part of a preventive care visit, will be routinely denied by insurance companies. The most common scenario is an uncovered laboratory test. Let’s say you are at your annual check-up with your primary care physician and you mention concerns about weight gain and fatigue. The doctor doesn’t find anything on your exam but decides to order a blood test to make sure your thyroid gland is functioning properly. Because thyroid tests are not included in the list of mandated preventive services, you will likely receive a bill for this test if it is submitted as part of a preventive care visit. The annoying thing is that if you scheduled a separate visit specifically to address your concern of weight gain and fatigue (incurring a separate copay, of course), this test would likely be covered.
Another example of an uncovered preventive health service is when a screening test that would normally be covered is performed on an individual who does not meet the guideline recommendations. For example, published guidelines recommend cholesterol screening in at-risk individuals every 4-6 years. If you are considered low-risk and your doctor orders a cholesterol screen every year as part of your health assessment visit, there is a good chance the charges for this test will be denied by your insurance company and you will be expected to pay out-of-pocket.
Many patients turn their anger toward the doctor when they receive these unexpected bills. However, keep in mind that your doctor does not benefit financially from ordering tests (there are laws to prevent this conflict of interest) and in most cases is doing her best to provide comprehensive care. Am I suggesting that patients need to know all of the healthcare guidelines and when they should receive certain tests? Absolutely not. Am I suggesting that doctors study the benefits manual for every health insurance company they accept so that they are intimately familiar with which tests are covered? Again, absolutely not. I do feel that primary care physicians should be knowledgeable about the recommendations and guidelines for preventive health services to ensure they are providing the best care to their patients. Figuring out whether that care will be covered by insurance falls to the patient. (Sorry.)
When you are seeing your doctor for a preventive visit (AKA “yearly checkup”), avoid saying, “Doc, I want to be checked for everything.” Allow the doctor to use his best judgment and the recommendations from reputable professional organizations. Additionally, if your doctor says, “Let’s just check a few additional things to be sure”, before going to the lab be sure to contact your insurance company to find out whether those tests will be covered. You can ask someone in the billing department of the doctor’s office to provide you with the name of the test and the billing code to ensure you are providing the correct information when you contact the insurance company. Be sure to tell them the test was ordered as part of a preventive health care visit.
In summary, here are my 3 tips for preventing surprise medical bills due to uncovered services:
- Review your health insurance plan thoroughly.
This is a repeat from Part 1 and will likely appear as a key recommendation in every article in this series. Make sure you are aware of your insurance plan’s coverage for medical services. Read the fine print. If you are not sure about your coverage, be sure to contact the insurance company. For non-emergent care, clarify your out-of-pocket expenses before receiving services.
- Do not immediately pay a surprise bill.
This was also mentioned in Part 1 of this series and is equally important. Insurance companies make mistakes. Perhaps the service should have been covered or maybe the doctor’s office inadvertently entered the wrong code for a covered test or procedure. Always contact the insurance company to clarify charges on surprise medical bills. If necessary, contact the doctor’s office as well.
- Don’t subscribe to the philosophy that “more is better” when receiving preventive care.
Just like there are certain services performed when you take your car to the shop for scheduled routine service, the same applies for preventive health visits. It is generally not advisable to ask the doctor to “just check everything”. While you should definitely share your health concerns during the annual checkup visit, allow the doctor to order tests based on established guidelines and recommendations. If it is necessary to order additional tests based on concerns or active symptoms, be sure to follow your doctor’s recommendations, but also contact your insurance company so you are aware of your out-of-pocket expenses. *Never forego recommended medical care due to cost. We should expect to pay some of the cost of our medical services. The goal is to avoid being surprised by these bills.
If you need assistance understanding your medical bills, health insurance, or anything else related to navigating the healthcare system, consider hiring a private health advocate. If you’re in the DMV area, I’d love to work with you. If you need help and cannot afford the services of a private health advocate, reach out to the Patient Advocate Foundation.
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As a pediatrician, I often get complaints about the way we billed. Sadly, it’s not the way we billed that’s the problem. It’s the way the insurance companies find loopholes. The depression screen example is a common problem. I can think of several instances where a parent declined having the depression screen done (which goes against standard of care, but I can’t force them to allow it), then several months later their teen is in a depression crisis. I don’t know if the depression would have been found earlier or if earlier treatment would have helped, but those parents usually regret their choice over a few dollars. Another example is the autism screen. I know several kids who had a delayed diagnosis, and looking back the parents declined the screening due to cost. Early treatment has been shown to have improved outcomes, and that opportunity is lost if there isn’t proper screening. It’s sad that they have to make those decisions in the first place. Insurance premiums are more and more expensive and cover less and less. We need change!
Dr. Stuppy,
Thank you for your thoughtful and informative comment. I agree wholeheartedly! It pains me that parents are foregoing critically important developmental and mental health screening due to cost. We say we have a “health” care system, but the insurance companies don’t want to pay for preventive services. We do need change!