Share on Pinterest
Experts say the biggest reason people get surprise medical bills is for receiving services that aren’t part of a person’s insurance coverage network. Pekic/Getty Images
  • Experts say most people in the United States are concerned about getting surprise medical bills, especially during the COVID-19 pandemic.
  • Experts say you can reduce your chances of getting such a bill by researching what your insurance company covers beforehand as well as getting a cost estimate from medical providers.
  • They also urge consumers to check all the charges when a bill arrives to make sure they’re correct, and that the insurance company has covered what it’s supposed to cover.

All data and statistics are based on publicly available data at the time of publication. Some information may be out of date.

The COVID-19 pandemic has made the high cost of healthcare, already a problem in the United States, even worse by increasing worries about unexpected medical charges.

Surprise medical bills represent a major financial burden for more than 2 out of 3 U.S. adults, according to a Harris Poll conducted for the American Heart Association.

Two-thirds of U.S. adults with private health insurance have received an unexpected medical bill, the poll found. Of those, 1 in 3 were unable to pay the bill.

A study published earlier this year in the Journal of the American Medical Association reported that 20 percent of hospital bills may contain surprise charges, even for people who are fully insured.

Both emergency and nonemergency treatment resulted in unexpected billing.

“Surprise medical bills are a major driver of financial anxiety and disruption for families nationwide that are already straining under the weight of an ongoing pandemic,” Dr. Mitchell S. V. Elkind, president of the American Heart Association and a professor of neurology and epidemiology at Columbia University Vagelos College of Physicians and Surgeons in New York, told Healthline.

One of the leading reasons people get surprise medical bills is because they unknowingly receive medical services from a healthcare provider, hospital, or medical transportation company outside of an insurer’s coverage network.

For example, a person might receive care from out-of-network specialists even when they’re undergoing procedures at a healthcare facility that’s in their provider network.

Conversely, in-network physicians may perform procedures at out-of-network facilities, resulting in surprise bills being sent to those patients.

“Health insurance plans are narrow and in some cases won’t cover [costs],” John Li, co-founder and chief technology officer at Fig Loans Inc., a company that provides loans to low-income households to cover emergency expenses, told Healthline.

“Surprise bills also happen when complications with patient treatments occur and expertise outside the network plan is required. Oftentimes, people are underinsured and are guided to use providers outside their network,” he said.

Surprise bills can also show up when insurers pay less of the cost of treatment than expected because patients are unfamiliar with deductibles for various services.

Errors are another common way that people get bills for excessive healthcare charges: Up to 80 percent of healthcare bills contain mistakes.

“The biggest mistake you can make is to see a bill and automatically pay it,” Gail Trauco, an oncology nurse and patient advocate who authored the book “Medical Bill 911,” told Healthline. “Chances are good that the number you see is an error.”

The nation’s piecemeal response to the COVID-19 pandemic has only increased opportunities for surprise billing, experts say.

As the American Heart Association noted, “The coronavirus pandemic has deepened concerns that patients are receiving care from out-of-network hospitals and providers because of overcrowding at in-network facilities, being surprise billed for COVID-19 tests and treatment, and struggling under the weight of financial pressures during the pandemic’s resulting economic crisis.”

“Throughout 2020, we have begun to see ‘COVID-19 fees’ added to medical bills, which is creating further confusion for (and distrust from) patients, impacting their overall experience,” said Dr. Florian Otto, co-founder and CEO of Cedar, a patient-centric medical billing platform.

“This is an issue that the healthcare industry can and must solve by integrating all these bills and fees into one consolidated statement,” he said.

Knowing exactly what your health insurance covers is a good first step toward preventing surprise medical bills from showing up in your mailbox.

“The best way to tackle surprise bills is due diligence,” Li said. “Do your research and clearly understand the clauses with your insurance provider and where you are or aren’t covered.”

“Deductibles, copays, coinsurance, and all those limits can be tricky, but understand them all before you seek services,” added Dr. Rafael A Lugo, owner and CEO of Lugo Surgical Group in Texas.

“This is also very important when picking your insurance. Everyone’s needs are different, and some plans work better on someone’s needs than others,” he said.

Lugo also advised asking ahead of time who will be providing your services and whether they’re covered by your health insurance.

Then, request that as many providers as possible be in your network.

“This is very important in the hospital setting where you may have different provider groups, like anesthesia and pathology, that are not in network,” Lugo told Healthline.

“The fact that you go to the hospital does not mean that all the providers there are in network. I wish it was like that, but everyone is independent and have different contracts. So always ask who is in network and who is not,” he said.

When possible, consumers should also demand a good faith estimate of what procedures will cost before consenting to treatment.

Hospitals and other providers “have the tools to be sometimes very close to the exact number” that procedures cost, such as by comparing insurance coverage with their own costs, said Lugo.

Dr. David Belk, an author and internal medicine specialist who runs TrueCostofHealthcare.org, said that people need to be mindful about what they discuss with their doctor during an office visit.

For example, an annual physical may be covered by insurance. But once patients start asking about other health problems, that opens up the possibility of additional exams and charges, Belk told Healthline.

“The person might have innocently asked about something like a mole they were concerned about, and the doctor might have looked at it and said, ‘Don’t worry, that’s just a mole,’” Belk explained.

“When the doctor (or his billing service) bills for the exam, though, they add a ‘code 25’ modifier, which allows them to add an extra charge to evaluate the skin lesion. If the patient has a high deductible, they end up paying the entire extra charge for that visit,” Belk said.

While some COVID-19 tests may be free of charge, like those offered via government health agencies, other tests can run into the hundreds of dollars beyond what insurance will pay. These can include certain tests for asymptomatic infections or tests conducted by out-of-network providers.

“Before the appointment, patients should directly ask their healthcare provider what out-of-pocket costs they should expect, including any COVID-19-related fees, whether or not a service like COVID-19 testing is covered by insurance, and if there are payment plan options available,” Otto said.

FAIR Health is a national nonprofit group focused on healthcare cost transparency.

Data gathered by the nonprofit can help people challenge unfair medical charges, said Trauco.

“Use the estimated cost in your area from FAIR Health to negotiate a lower medical or dental cost or payment plan,” she advised.

Challenging surprise medical bills will require writing letters or making phone calls to healthcare providers and insurers.

“When you receive your bill, examine the items, and if anything isn’t clear to you or seems incorrect, ask for clarification and corrections,” said Ian Wright, CEO of Bequests, a retirement and end-of-life planning information portal. “The bottom line is that you need to take the initiative.”

Your success in challenging a surprise medical bill will depend in part on what evidence you have on hand, especially a cost estimate from your provider that was prepared before the procedure, said Jeff Grobaski, founder and CEO of Epic River, a lending company that works with people, hospitals, and doctors to resolve medical billing conflicts.

Grobaski told Healthline that because healthcare providers can’t easily predict the cost of most procedures ahead of time, patients aren’t required to sign a contract promising to pay their bills.

That opens a window for negotiations.

“You need to contact your healthcare provider early and often, and plead your case,” Grobaski said.

If there are errors on your bill, “you also can get your insurer to work on your behalf,” he said.

“There’s not a huge likelihood that an insurer will say, ‘OK, we will cover that’” if you get charged for services from an out-of-network provider, Grobaski said. “But there’s a higher likelihood of them helping you find an error.”

“The best approach is to talk to everyone” — hospitals, doctors, and insurers — “and get everyone to reduce their charges a little bit,” he said.

Doing so could result in significant reductions in surprise bills, although to get your cost down to zero usually “will involve lawyers,” Grobaski said.