Gaps in Medical Coverage: What To Do When You Get an Unexpected Bill

There are many reasons that one can get billed for what they expected their health insurance plan would cover. Sometimes, you may have the best, a platinum plan, or the most comprehensive Medicare Advantage plan that does not pay for services in full, leaving a gap in medical coverage that can only come out of your pocket. Although mistakes do happen with billing code errors and the like, often there’s a reason you’re being billed, like service from an out-of-service provider or hospital, even if it was an emergency visit or the primary physician was in-network. Here are some common surprise bills and examples of gaps in coverage and what you can do to rectify the problem or better manage your unanticipated new debt.

On This Page

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  Common Types of Surprise Bills and Gaps in Coverage

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  Out-of-Pocket Medical Costs That Can’t Be Avoided

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  Even the Best Health Insurance Plans Have Gaps

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  How Coinsurance Works, and Why You May Be Getting a Bill

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  What Should I Do if I Get a Surprise Bill?

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  Surprise Medical Bills FAQs

Common Types of Surprise Bills and Gaps in Coverage

There are several reasons you may get billed directly from a provider, if your health insurance does not cover the cost. Here are the most common types of surprise bills:

• You had surgery at an in-network hospital, but the anesthesiologist was not in your health insurer network. The anesthesiologist will send you a bill.
• You went to an in-network lab or imaging center for tests and the doctor who read the results is not in your insurer's network. That doctor will send you a bill.
• You may have Medicare and supplemental insurance but neither one will pay the medical bills in full if you get treatment for, say, cancer.
• A consumer who is taken to the nearest emergency room may also receive a bill from the emergency facility for the remaining balance of the bill that was not paid by their health plan.
• A mistake in billing by the medical provider or coverage group.
• 20% of surprise bills were a result of a doctor not being part of the network.^[1]
• 53% of surprise bills were for a healthcare provider while 51% were for lab tests.^[1]
• 43% of surprise bills were hospitals or other health care facility charges.^[1]
• 35% of surprise bills were for imaging and 29% were for prescription drugs.^[1]

Some states, like California, have passed a law which prevents providers from sending surprise bills when they use an in-network facility. Even if your state does not have this type of law, the Federal No Surprises Act protects patients from many of these types of surprise bills as well.

Out-of-Pocket Medical Costs That Can’t Be Avoided

Copayments that go with expensive treatments may leave a gap in insurance, even if you try to fill the gaps with supplemental health insurance. And the gaps may be as high as $1,000 in out-of-pocket expenses each month, for cancer treatments and the like.

Also, experimental treatments are almost always excluded from coverage. People also lose sight of the fact that certain medical services, like physical therapy, have maximums, even if prescribed by a doctor. Once you reach the policy’s limit, you will have to pay for sessions on your own. Note that out-of-network maximums can be significantly higher than in-network ones, sometimes twice as much.

A medical-billing advocate may be able to help negotiate down out-of-pocket expenses and set up a manageable payment plan if you’re unsuccessful in getting the cost waived. But you must act before the bill goes into collections, at which point it will no longer be in the hands of the provider.

The Federal No Surprises Act protects patients from many of these types of surprise bills but not all.

Even the Best Health Insurance Plans Have Gaps

You can have a great health insurance plan and still end up in medical debt when providers do not give you prices beforehand. Also, providers are not perfect; mistakes happen, like confusing an HMO plan for a PPO plan (if they offer both), so sometimes you may get billed incorrectly. Try to get someone on the phone if you get a bill that seems wrong. You may be able to get to the bottom of a clerical error and not owe anything.

Sometimes, however, it is impossible to get pricing before a procedure, especially if it’s an emergency visit. And it’s not your imagination that providers are sometimes guarded about revealing pricing because they have various contracts with different insurance companies and can’t really give you figures without knowing all the details. And sometimes, providers just don’t know yet which types of treatment or services you’ll need initially.

How Coinsurance Works, and Why You May Be Getting a Bill

PPOs, POS and EPOs may charge a co-insurance, or percent of the bill, when you get a covered service from an out-of-network doctor. Instead of paying a fixed amount each time you receive medical care, such as a copay, you may be required to pay a percentage of the total costs. For example, your insurance company may pay 80% of the bill, and you may be responsible for the remaining 20% of the total cost.

What Should I Do if I Get a Surprise Bill?

First, go over the bill and check for errors and make sure the billing code is the right one for the treatment(s) you received. Request an itemized list of costs if applicable.

You can file a grievance/complaint with your health insurance company and include a copy of the bill. Your health plan will review it and tell the provider to stop billing you, at least until the grievance is resolved.

If you do not agree with your health insurance company’s response or if they take more than 30 days to respond, you can file a complaint with your state’s Department of Managed Health Care.

If all else fails, contact the billing department of the provider charging you and ask if you can have a reduced fee. Also, ask for a manageable payment plan.