How to protect yourself from surprise medical bills in New Jersey

March 22, 2021

Tips to avoid surprise bills and lower your medical bills

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 only revealed when the bill arrives in the mail. The average emergency room surprise bill is around $600, but these bills can range into the tens or even hundreds of 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 New Jersey, some consumers are protected from certain surprise medical bills. It is important to know your rights to protect yourself from these illegal out-of-network charges. If you have insurance through Medicare or NJ Family Care, 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 New Jersey 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. This includes any testing ordered by an in-network provider but done by an out-of-network laboratory.

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.”

To be protected under New Jersey’s surprise medical bills law, you must be insured either by a state-regulated plan or be covered by one of the federally regulated plans that has chosen to take advantage of these protections. To find out whether your plan offers these protections, contact your insurer. You could be required to pay an out-of-network bill in the following situations:

If you knowingly, voluntarily, and specifically choose a provider or facility not within your insurance network.
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.

Voluntarily choosing an out-of-network provider

Many insured New Jersey residents are covered by an HMO plan which does not cover out-of-network services. But if you do have a plan that has an out-of-network benefit, you can still choose an out-of-network provider at an in-network facility. However, actively choosing an out-of-network provider will result in a higher copay and additional costs your insurer will not cover.

You can only be billed for these higher out-of-network charges if, at the time of making an appointment, these conditions were met:

You were told that the provider was not covered by your insurance network,
You were given an option to choose an in-network provider, and
You signed a form consenting to the out-of-network treatment. If there are no in-network providers available, you cannot be billed beyond your in-network cost-sharing amount, even if you sign a form consenting to the out-of-network treatment. This is also true for emergency situations.

How to prevent a surprise bill

Because New Jersey’s law does not protect everyone and every situation, here are a few steps you should take to prevent a surprise 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, do not pay 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 consumer protections. Here 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:

Is your insurance plan a state-regulated plan or has your plan opted in to the protections? If you are unsure, contact your insurer or the Department of Banking and Insurance at 1-800-446-7467.
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 Department of Banking and Insurance online or by phone at 1-800-446-7467.

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 New Jersey’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 Department of Banking and Insurance at 1-800-446-7467. 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 New Jersey, you can be tested at Walgreens, Walmart, Rite Aid, 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 and insurance plans are 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 New Jersey residents covered by federally regulated plans who are currently without protections under New Jersey law will be protected from surprise bills beginning in 2022. The federal protections will closely mirror New Jersey’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 law will also prevent air ambulances from sending out-of-network surprise bills.

Last updated March 12, 2021