Health Insurance Provider Networks and Avoiding Surprise Bills

It’s the kind of surprise nobody wants: staying on top of your medical expenses only to find you’ve accidentally used an out-of-network doctor and now face a huge bill.

The situation is common enough to have a name: surprise medical billing. It happens most often when patients go to a hospital in their provider network where a non-network doctor happens to practice. Health insurance covers the charges as outlined in the policy, except for fees from out-of-network doctors who treat you, which can be thousands of dollars depending on the length of the hospital stay and complexity of the treatment.

Worse, any over-billed amount you owe doesn’t count toward your health insurance deductible or out-of-pocket maximum.

Since it’s unreasonable to expect consumers to research every physician at a hospital before they seek emergency care, many states protect against surprise billing. Several states have enacted laws to address balance billing, especially when it results from an emergency. Here’s a report on balance billing from the Robert Wood Johnson Foundation and the Center on Health Insurance Reforms.

Still, a majority of states don’t protect consumers from out-of-network charges, so you should know how a provider network works and how to stay within yours — and what to do if you get a surprise bill.

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