Surprise medical billing is a large issue being discussed across the country.

If you have insurance, you would probably call the hospital or your insurer first to make sure the hospital was “in network” with your insurance.

You might also need to double-check that the surgeon who will be operating on you is in-network, too.

But even if you do your homework before your elective surgery, you can still be at risk of receiving large bills you never would have expected, from providers you’ve never met or even knew about.

According to a recent JAMA study, surprise bills happen about a fifth of the time that a patient has an elective surgery at an in-network hospital with an in-network surgeon.

The average unexpected charge of about $2,000 more than what insurance would typically pay can hurt anyone, especially vulnerable populations.

What is Surprise Medical Billing?

Surprise medical billing occurs when a patient receives a larger-than-expected medical bill due to their care provider being out-of-network.

In most situations, the patient is not aware that they received out-of-network care so it comes as surprising. It typically occurs in the following scenarios:

  • Emergency care situations and nonsurgical hospital stays, when patients may not be able to choose health care providers covered by their insurance.
  • An out-of-network provider renders service to a patient at an in-network hospital.
  • In situations with surgical complications as the procedure grows more complex, more people get involved in treating it and one or a few might be out of network.

Most of the surprise bills come from either anesthesiologists or surgical assistants — who are typically not chosen by patients. They could also come from out-of-network pathologists, who analyze tissue and blood samples, or radiologists, who examine X-rays and MRIs.

How Do Patients View Surprise Medical Bills?

Surprise medical billing is leaving patients all over the country with large unexpected medical expenses, sometimes totaling hundreds of thousands of dollars.

According to a new study by Yale researchers, addressing the issue could reduce health spending by 3.4% which translates to $40 billion annually.

Many patients view surprise medical billing as an unfair and unjust practice in the medical community. Surprise medical billing often leads to financial hardship for patients who are not prepared to pay the large sum.

Most often, this unexpected medical cost falls in their lap after unplanned emergency care. When a patient enters the emergency department, they are not considering that a doctor, whom they do not know, would be out-of-network in a hospital they know to be in-network.

Legislation To End Surprise Medical Bills in 2021? 

After several years of working to enact a ban on surprise medical billing, Congress included the “No Surprises Act,” in the end-of-year legislation.

The omnibus spending and COVID relief bill signed by President Donald Trump on December 27 included a measure to prevent patients from being billed by out-of-network doctors after treatment in an in-network hospital.

The legislation bans surprise medical billing for emergency and nonemergency care.

Patients are only required to pay to the in-network cost-sharing, including any applicable co-payment, coinsurance and deductible for out-of-network emergency medical care at in-network facilities.

For nonemergency care, patient-informed consent is required for patients to be balance billed.

The legislation also establishes an arbitration process for resolving out-of-network provider claims to be paid by health plans. There is a 30-day open negotiation period for providers and payers to settle out-of-network claims.

Hopefully with this legislation, patients would no longer have to fight these surprise medical bills at the same time they are facing a medical crisis.


About Mnet Health

We believe every patient deserves a helpful, transparent, easy to navigate financial experience in healthcare.

Mnet is the premier revenue cycle management & technology provider to the surgical industry. We provide custom patient-pay solutions to surgical hospitals and ambulatory surgery centers. As of 2020, Mnet Health partners with over 700 surgical facilities nationwide and is the preferred vendor of both United Surgical Partners International (USPI) and Surgical Care Affiliates (SCA) – both directly with and in support of centralized billing offices.

Mnet’s custom brand, PaySUITE, is a white-labeled payment technology platform that helps surgical facilities and their providers grow their business by helping patients pay. Mnet’s patient-pay solutions significantly increase self-pay collections while creating a better financial experience for patients. For more information, visit https://mnethealth.com.