Imagine you go to a hospital for a routine procedure. You’ve made sure your hospital and doctor are covered by your insurance. The procedure goes well and you head home to recover. Two weeks later, you get the bill, but instead of the copay you expected, you get a bill for nearly $4,000. Turns out, the anesthesiologist who assisted with your procedure was “out of network” and your insurance won’t cover that bill as you expected. You’ve received a surprise medical bill and now owe the difference between what your insurance will pay the out-of-network anesthesiologist and what you were billed.
What is a “surprise” medical bill?
You receive a surprise medical bill when, through no fault of your own, you are treated by providers outside of your insurance network. These out-of-network providers can charge exorbitant rates which are only revealed after the bill arrives. An average emergency room surprise bill is around $600, but these bills can range into the thousands of dollars. When out-of-network providers charge these high rates, it drives up costs for everyone. Consumers are burdened with higher bills that they had no way to avoid. And when insurers have to pay their share of this higher charge, they’re likely to pass on that cost to everyone by raising premiums.
Know your rights
In Georgia, a new law protects consumers with state-regulated insurance from certain surprise medical bills. These protections do not apply to self-insured plans, also known as ERISA plans, which include most employee-sponsored plans. If you are unsure whether your plan is state regulated, contact your insurer. If you have insurance through Medicare or Georgia Medicaid, or are on Veterans Affairs Health Care, you are fully protected from surprise bills. These consumer tips are for people covered under any other type of insurance.
If your insurance plan is regulated by Georgia state law, you are protected from surprise bills in these two situations:
Emergency treatment by an out-of-network provider or facility.
Treatment by an out-of-network provider at an in-network facility which would normally be covered by your insurance.
In these situations, you cannot be charged for anything more than what you would normally owe for in-network treatment. The out-of-network provider should not send you a bill. If you do receive one, inform your insurer at once and follow the steps below on “How to fight a surprise bill.”
Exceptions to Georgia’s surprise billing protections
There are certain instances where Georgia’s law will not protect you from out-of-network charges. You could be required to pay an out-of-network bill in the following situations:
If you specifically chose an out-of-network provider. You can only be billed for these higher out-of-network charges if these conditions were met:
You were told that the provider was not covered by your insurance network.
You were given an estimate of the cost of treatment and it was made clear to you that the cost would be greater than if you used an in-network provider.
You signed a form and gave oral consent to the out-of-network treatment.
* See the section below “Choosing an out-of-network provider” to learn more about these situations.
If you request your attending provider for a referral to another provider who is not in your insurance network. See the section below “Provider referrals” to learn more about this situation.
If you are transported by an out-of-network ground or air ambulance. See the section “tips for lowering a medical bill” below to learn how you can try to lower your bill from ambulances not covered by your insurer.
Choosing an out-of-network provider
Many insured Georgia residents are covered by an HMO plan that does not cover out-of-network services. But if you do have a plan that has an out-of-network benefit, you may choose an out-of-network provider at an in-network facility. However, choosing an out-of-network provider will result in a higher copay and additional costs your insurer will not cover. Be sure to think carefully before choosing or consenting to treatment by an out-of-network provider or facility.
You may be responsible for an out-of-network bill if you request your attending doctor to refer you to another provider. Because that provider could be out-of-network, the new law requires the attending doctor who makes the referral to inform you that your new provider may be out-of-network and may therefore cost you more. You will be given a separate form to sign that says you are aware of this information. If you sign this form and give oral consent, you are waiving your right to surprise billing protections. Before signing this form and agreeing to see another provider, check with your insurance company to determine if the new provider is in your network. It is best to have that information before agreeing to see a referred provider; otherwise, you risk getting a more expensive out-of-network bill.
How to prevent a surprise bill
Because Georgia’s law does not protect everyone in every situation, here are a few steps you should take to prevent a surprise medical bill.
Check with your insurer to make sure you are choosing a provider that is covered by your insurance. Make sure that the hospital or health care facility (lab, diagnostic center, surgery center) is in your insurance network before receiving treatment.
When planning hospitalizations at an in-network facility, check with the facility to ensure that all providers (surgeons, anesthesiologists, and others), lab services (such as blood work) and imaging services (such as X-rays, MRIs) are covered by your insurance plan. Be specific in requesting that all services you may need are covered by your insurer.
For emergencies, know where your nearest in-network emergency room is and use it whenever possible.
What to do if you receive a surprise medical bill
If you receive a surprise out-of-network charge or think your bill is incorrect, use these tips to attempt to lower a medical bill:
Make sure you are looking at an actual bill or invoice. An “Explanation of Benefits” is not a bill.
If the bill looks incorrect, ask questions before paying it. Sometimes bills are sent before the insurance company has made its portion of the payment. Call your insurer and ask for more information.
If you think you have received a surprise medical bill, you can fight the charges. But first, be sure the bill is covered by Georgia’s surprise billing protections. There are a few questions to ask. If you are able to answer yes to all these questions, then you do not have to pay the bill, unless you have waived your rights by signing the form mentioned in “Provider referrals” above:
Is your insurance plan a state-regulated plan? If you are unsure, contact your insurer or the Office of the Commissioner of Insurance and Safety Fire at (404) 656-2070
Is the bill for more than your typical copay for in-network services?
Is the bill for treatment in an emergency room?
If the care was not in an emergency situation, was the facility in-network?
If you think you’ve been sent a bill you should not have to pay, file a complaint with your insurer. Then file a complaint with the Office of the Commissioner of Insurance and Safety Fire online or at (404) 656-2070.
* If your bill does not meet all the requirements above, you may still be able to lower the amount you owe. See the next section.
Tips for lowering a medical bill
If your plan is not protected by Georgia’s law or you receive a surprise bill for ambulance transport or some other reason, you may be able to lower the amount you owe by negotiating with your provider and insurer. Use these tips to try to lower your bill:
Ask for an itemized bill and check that you are not being mistakenly billed for treatment you did not receive.
Compare the itemized bill to your Explanation of Benefits to see whether your insurer is paying their share. Sometimes patients are billed for services because their provider sent the wrong billing code to the insurer.
Contact your provider and ask about anything you don’t understand.
Contact your insurer to see if any mistakes were made on their end.
If there are no mistakes, try negotiating with your provider. Many hospitals have patient advocate departments to help you negotiate the bill.
Contact the Office of the Commissioner of Insurance and Fire Safety online or at (404) 656-2070. They may be able to help you fight the bill.
Keep careful notes of all conversations you have. Get the names of the people you are speaking to. Keep your files in one place for easy access.
Be patient and clear in your requests.
Special information during the COVID-19 pandemic
Testing for COVID-19 is free for both insured and uninsured consumers. Health plans are required to cover the cost of testing (even if you don’t have symptoms or have not been exposed to someone with COVID-19). This means that if you want to be tested for any reason, such as before visiting a family member, your insurance must pay for the test and cannot bill you for any copay, coinsurance, or deductible.
Even though the test is free, many people have been billed for other fees, such as a “facility fee.” When you choose a testing site, call to be sure there are no additional fees. In Georgia, you can be tested at Walgreens, Walmart, CVS, eTrueNorth, and Health Mart at no cost. You do not need a referral to be tested at these pharmacies, but you do have to arrange an appointment beforehand. To find out more about COVID testing in your state, use this resource.
Note on vaccines: Many Americans are now able to register for a COVID-19 vaccine. These vaccines are free to consumers. Insurance plans are also required to pay for any associated administration costs without cost-sharing. If you do receive a bill related to your COVID-19 vaccine appointment, contact your insurer. You are not required to pay any cost-sharing (copay, coinsurance, or deductible) related to getting a vaccine against the COVID-19 virus.
More consumer protections are coming in January 2022
In a victory for consumers, Congress passed the No Surprises Act to expand surprise billing protections to all insured Americans. This means that Georgia residents covered by federally regulated plans who are currently without protections under Georgia’s new law will be protected from surprise bills beginning in 2022. The federal protections will closely mirror Georgia’s laws, protecting patients from surprise out-of-network bills for emergency treatment and from surprise bills for non-emergency treatment at in-network hospitals. The No Surprises Act will also prevent air ambulances from sending out-of-network surprise bills.
Last updated April 7, 2021