- What is surprise billing? Surprise billing is the unpaid balance for services rendered by an out-of-network provider
- Most health plans distinguish between in-network and out-of-network providers and pay them accordingly
- A large number of plans pay a lesser amount to out-of-network providers
- Some plans pay nothing to out-of-network providers
- A patient may receive a surprise statement when an in-network facility contracts with out-of-network ancillary providers.
- Ancillary providers include surgeons, anesthesiologists, radiologists, and pathologists
- Patients receiving emergency care for accident injuries may receive a surprise bill from out-of-network providers. Our attorneys recommend discussing these charges with their personal injury attorney
- The Airline Deregulation Act of 1978 regulates emergency air transport services
- It is unknown at this time how far federal legislation will go to protect the pockets of Indiana accident victims treated or transported by out-of-network providers
- Indiana passed legislation against surprise billing in 2020 but failed to include protections for accident victims who were transported or unwittingly treated by out-of-network providers.
No doubt by now you have heard about a practice known as Surprise Billing, commonly known as Balance Billing. The term surprise billing accurately describes a patient billing generated by an out-of-network treating healthcare provider, most notably for treatment received in an emergency facility after an automobile crash, trucking collision, or motorcycle accident. “We see this all the time in our law practice, states Indianapolis eastside motorcycle accident lawyer Charlie Ward, when our injured clients have been transported and/or treated in trauma centers across Indiana.”
What is surprise billing?
First, allow me to explain a bit about healthcare benefits and how they apply to your medical bills.
What is an Explanation of Benefits (EOB)?
An Explanation of Benefits commonly referred to as an EOB is a statement from the health insurer, (group, individual, Medicare, etc.) listing charges and benefits paid for medical services rendered to the patient. The EOB will reflect any healthcare provider discounts contractually required, co-pays, insurance payments made to the provider (if any), along with any balance you might owe for the provider’s services. If you have not yet met your annual deductible, your insurance company will also factor out-of-pocket costs into your portion of the bill.
For each medical bill incurred, an EOB is generated by your health insurance company to explain how your benefits were applied. By the time you access your Explanation of Benefits, the health insurer would have already settled their portion with your medical provider. The patient, guardian, or estate will receive the remaining balance from the medical provider.
Provider discounts are a fundamental benefit of your policy
Consumers are aware that healthcare services are not only excessively high but appear extremely unreasonable without the benefits provided by health insurers. If it were not so, Medicare would compensate more than a “reasonable,” fractional reimbursement rate to Medicare-assigned providers, compared with the marketplace, group, and individual cost-share rates of reimbursement. But a key benefit that insurance companies offer their customers is the discount on services, prescriptions, vision, and dental.
Your healthcare plan is a binding contract between you and your health insurance company. By joining a health plan, you receive discounts that uninsured patients do not receive. Most employer-offered insurance, individual, and marketplace plans make a distinction between in-network and out-of-network healthcare facilities and providers.
Healthcare insurance companies negotiate a contract with in-network medical facilities and providers. The insured receive discounts passed down from their health insurance contracts. The plan honors the negotiated rate for each service provided by your in-network healthcare providers. And a lesser rate or naught, for services provided by an out-of-network provider. In the end, how much the plan reimburses the provider depends upon their network status and the patient’s remaining deductible. After the plan pays their portion, the provider bills the patient who is responsible for the balance of the bill―hence the term “Balance Billing.” For services provided by an out-of-network provider, the balance bill can be excessive and shocking.
Why would an insured patient or accident victim receive a surprise billing?
Patients who unknowingly treat with out-of-network providers often receive surprise billings. But accident victims are not alone! Even non-accident patients also may receive surprise charges in the mail.
The following is a list of events that may trigger an out-of-network surprise bill:
- Pre-scheduled surgeries or treatments at in-network medical facilities contracting with ancillary staff who are outside your network
Hospitals and emergency care facilities contract with ancillary providers such as radiologists, anesthesiologists, and pathologists for staff positions. These on-staff providers may or may not be providers within your healthcare network. Surgeons often select their anesthesiologists because they share a history of working well together. Treatment by out-of-network providers would likely result in an unexpected, sizable, surprise, or balance billing.
- Out-of-network facility and/or care provided by out-of-network staff arising out of an ER visit. The nearest trauma centers logistically facilitate emergency care and treatment. And do so without considering the patient’s health insurance obligations. But your personal injury lawyer may have a toolbox of strategies that, when employed, can reduce emergency expenses from out-of-network medical providers.
- Emergency air transport to a trauma center
Serious accidents often occur on the backroads and highways of remote, rural areas of Indiana. And though all 92 Indiana counties have a treatment facility, extreme and catastrophic injuries require advanced diagnostics and treatment. Transportation from rural locales to major metropolitan trauma centers often requires transport by air ambulance. The Airline Deregulation Act has regulated emergency air-transport services since 1978. And many patients air-lifted to Indianapolis receive bills for $25,000 – $50,000, and up.
Does Legislation Protect Insured Patients?
In 2020 and 2021, Indiana and the federal government passed respective legislation to protect insured patients from surprise billing.
The legislation passed by the Indiana General Assembly has yet to address surprise bills generated from emergency room visits. Our law firm will eagerly watch for the Indiana Assembly to address this loophole in the current legislation.
The federal legislation entitled the “No Surprises Act” is somewhat vague in that the intent of the Act is to protect medical consumers in states where balance billing policies are non-existent. Over time, the courts will test and try any limitations of the Act. But until that time arrives, the question persists. “Will the No Surprises Act shield accident victims intentionally excluded from state legislation?”
Experienced Indianapolis Eastside Motorcycle Accident Lawyer
Ward & Ward Law Firm* is a personal injury law firm with nearly a century of combined experience in personal injury law, representing plaintiffs who have been injured through no fault of their own. The courts will sort out problems that may arise from the legislation. Until such time, call your accident lawyer with questions about your out-of-network charges. You may also be interested in our firm’s article about the RAP Clause.
Call 317-639-9501 and ask for attorney Charlie Ward to discuss your accident claim without obligation.
*Ward & Ward Law Firm is a contingency law firm and does not get paid unless we recover for our clients.
This article is not legal advice. Discuss any concerns with your injury attorney.