Receiving a surprising hospital bill following an emergency visit can significantly add to the stress of an already challenging time. However, experts highlight that various federal and state regulations exist to safeguard individuals from being overcharged for medical services.
Understanding Your Hospital Bill
According to JoAnn Volk, a research professor at Georgetown University’s Center on Health Insurance Reforms, the experience can feel daunting. “Take a moment to breathe and assess whether any claims have been denied. There are options available, so don’t accept refusals without exploring them first,” she advises.
Mosaic consulted with Volk to gain insights on how to effectively manage and address hospital bills.
Action Steps Upon Receiving Your Bill
Q: What should be your first step when you receive a hospital bill?
A: Your insurance provider will either send a bill through traditional mail or via a patient portal outlining what costs they covered. It is essential to review this document to understand what has been covered and what has not.
Dealing with Denied Coverage
Q: What should you do if your insurance denies coverage for treatment?
A: If you find that the bill indicates denial of coverage, federal laws stipulate that insurers must provide a rationale for such decisions. You have the right to appeal the denial with assistance from your healthcare provider.
Further Actions if Your Appeal is Denied
Q: What recourse is available if your appeal also gets denied?
A: Under federal regulations, you can challenge the denial once more and request an independent review of your insurer’s decision. This additional review determines whether the treatment should have been covered—though it is worth noting that this process might take several months.
Understanding Denial Reasons
Q: What does a denial citing “failure to obtain prior authorization” mean?
A: Federal law explicitly prohibits insurers from requiring prior authorization for emergency services. In urgent medical situations, it is unreasonable to expect individuals to pause and complete paperwork to gain authorization for essential emergency care.
Navigating Out-of-Network charges
Q: If I utilize an out-of-network hospital during an emergency, will my insurance incur additional charges?
A: For emergency situations, federal law mandates that insurance plans must apply the same coverage rates for both in-network and out-of-network services.
Self-Inflicted Injuries and Insurance Coverage
Q: Are insurance companies obligated to cover treatments for self-inflicted injuries, like those resulting from a suicide attempt?
A: Per federal regulations, if an insurance plan covers treatment for accidental injuries, it must also cover care related to self-inflicted injuries. Therefore, if an insurance provider covers an emergency room visit, they cannot deny coverage merely because the visit stemmed from a self-inflicted injury.
Working with High Medical Bills
Q: What options are available if my medical bills exceed what I can afford, even with insurance?
A: Federal laws require nonprofit hospitals to provide financial aid to individuals struggling to pay their medical bills. Your hospital may have a financial assistance program that can help reduce or potentially clear out-of-pocket costs that exceed your financial capacity. Additionally, New Jersey mandates that all hospitals offer this assistance based on a patient’s income.
Options for the Uninsured
Q: What should you do if you lack insurance coverage?
A: Under federal law, hospitals are obliged to treat and stabilize any patient, regardless of their insurance status. However, once a patient is stabilized, the hospital is not legally required to continue treatment, and the individual would then be responsible for the costs associated with any further care.
