Avoid surprise medical bills by following this prescription

Take the time to kick the tires on your health insurance choices during open enrollment — it could help you reduce the chances of a surprise medical bill.

Over the past year, 20 percent of working Americans have had a problem paying medical bills, according to a survey from the Kaiser Family Foundation. Many of those stemmed from unexpected bills: For 26 percent, it was a claim their insurer denied, and for 32 percent, a surprise bill from an out-of-network health-care provider.

(The survey polled 2,575 adults in the fall of 2015, with a margin of error of plus or minus 3 percentage points.)

"This is an issue that sophisticated, active consumers can't solve on their own," said Paul Ginsburg, a senior fellow at Brookings Institution.

Surprise medical bills often stem from an interaction with an out-of-network provider that's out of the consumer's control, he said — say, you call 911 and the responding ambulance is out of network. Or you choose an in-network hospital and surgeon for surgery, but the on-duty anesthesiologist is out of network. Or your in-network primary care physician sends your routine bloodwork to an out-of-network lab.

This is an issue that sophisticated, active consumers can't solve on their own.
Paul Ginsburg
senior fellow, Brookings Institution

That said, understanding your health plan could help you avoid some surprises and have a better sense of what to do if you do get an unexpected bill, said Thomas Torre, chief executive of CoPatient, a company that helps consumers resolve billing errors.

Among consumers surprised by health-care costs, 39 percent said they "only somewhat" understand their current health benefits — and 20 percent said they don't know what kind of health insurance plan they have, according to a survey from CoPatient. (The company polled 1,138 consumers in September, 515 of whom said they had been surprised by health costs over the past year. The margin of error is plus or minus 4 percentage points.)

"In general, the way things are going, more and more responsibility is being shifted to consumers," said Torre. Some of those changes are easy to spot during open enrollment, he said — namely, higher premiums and deductibles. (This week, officials revealed that the average premium for benchmark Obamacare plans is set to rise 25 percent in the 38 states served by "But sometimes it's not so obvious where the network has been changed, that there are fewer specialists and other players in network," he said.

"If you make a bad plan choice, it's really impactful," Torre said.

Here's what to look for in your health plan options and employee benefits during open enrollment that could alleviate the impact of an unexpected medical bill:

Assess surprise bill protections

Some states have laws protecting consumers from surprise out-of-network bills stemming from emergency care and other specific instances. But according to an October report from Brookings Institution, consumers in some kinds of plans (like Medicare) are more protected than others. State laws that target insurers (rather than health-care providers) don't extend to those employees in plans that aren't state-regulated.

Ask your insurer about protections for surprise bills, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Even if there's no state law protecting you, the policy may have a provision holding you harmless for surprise out-of-network charges in some circumstances. That's helpful to know if you're erroneously billed.

Ask for help

Nearly half of large and mid-size employers offer health advocacy services as an employee perk, according to an analysis from benefits consulting firm Aon Hewitt. Another 43 percent are considering adding those services within five years.

If you have access to such services, using them up front can help you navigate the system to get a better sense of costs ahead of time and make decisions that reduce the chances of an unexpected bill.

Check provider participation

"It's almost impossible to be too careful about making sure the provider is in your plan's network," said Ginsburg.

Start by using the "find a provider" tool on your insurer's website. Then confirm with a call to the provider's office to ask if they accept your insurance, and if they are in-network or out.

"Unfortunately, the provider networks are not always up to date," said Ginsburg. "The fault is somewhere between the providers and the plans."

Double check even if it's your primary care physician making a referral to a specialist working at the same in-network facility, he said. That provider could still be outside the network.

When you're assessing plan options during open enrollment, double check that all your regular doctors are still in-network under the new plan, said Torre. While you're at it, confirm which of the local hospitals are covered, just in case.

If you're anticipating a big medical event in the coming year — say, you're planning to have a baby or have been putting off knee surgery — it's smart to research in-network options for that care, too, he said.

Understand plan coverage

It's important to have a sense of just how much you could be on the hook for if you step out of bounds. Depending on your plan, an out-of-network charge may mean insurance covers less of the cost — or nothing at all, said Claire McAndrew, private insurance program director for Families USA, a health-care advocacy group.

Among Affordable Care Act plans for 2016 sold on, 59 percent did not have standard out-of-network coverage, up from 47 percent of the 2015 plans, according to an analysis from comparison site HealthPocket. In most of those plans, they found, the insurer would not pay for out-of-network costs except in the case of prior authorization from the plan or a medical emergency.

Don't just worry about in- or out-of-network distinctions. Tiered health insurance plans vary coverage based on where an in-network provider falls in the ranking system, McAndrew said. When in doubt, ask your insurer which tier includes your doctor.

"If they go to a provider on a higher tier, they will pay more out-of-pocket," she said.