The Best Medical Billing Surprise Is No Surprise.

• Author: Becker, Colleen
• Position: HEALTH CARE

After falling off a ladder, Jerry was taken by ambulance to a hospital within his insurance network. Over the course of 10 days he had surgery and received care from six different doctors, along with X-rays and an MRI.

After returning home, he was surprised to receive bills for thousands of dollars on top of his $5,000 deductible. No one told him that even though the hospital was in the network, the doctors and the lab weren't. The billing company told him to appeal to his insurance carrier to pay the bill. If the company refused, however, he would be responsible for the charges.

Jerry's experience is not unusual. Surprise billing, known in the industry as balance billing, affects all demographics. In fact, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge, according to a Kaiser Family Foundation survey. In addition, 4 in 10 respondents said they had received an unexpected medical bill in the last 12 months; 1 in 10 reported receiving a surprise bill from an out-of-network provider. And, according to another report in the journal Health Affairs, 1 in 5 patients received care at an emergency department outside their provider's network.

No One Is Immune

You can incur charges even before you get to the hospital. Transportation provided by land or air ambulances can lead to enormous out-of-network bills. A 2014 study found that 26% of ambulance trips were considered outside the patient's private insurance network.

Health insurers limit their networks to help control costs. But if there are not enough in-network doctors and services, patients are likely to need out-of-network health care, especially in an emergency.

The National Association of Insurance Commissioners, which oversees carriers, created a model act for state lawmakers to use as a road map for protecting patients against balance billing. To date, Colorado, Georgia, Hawaii and Maryland have adopted the NAIC model act.

Currently, nine states have comprehensive consumer protection laws against surprise billing, while another 16 have partial...