Have you or anybody you know received medical treatment that you thought was covered by insurance, only to receive a surprise bill that isn’t covered? If so, you’re not alone.

In the past two years, a whopping one out of three privately insured Americans received a “surprise” medical bill, according to a Consumers Union survey published May 5^th. CU described a “surprise” medical bill as one you weren’t expecting or where the health plan paid less than expected.

CU surveyed 2,200 adult U.S. residents as well as additional persons in Ohio (622), Florida, California, and Texas. The survey also found that nearly nine out of ten consumers don’t know the state agency or department tasked with handling health insurance complaints.

To understand why surprise medical bills are a growing concern to consumers, you need to know a few insurance terms.

Providers who are “in network” vs. “out of network:” Most health insurance plans contract with providers of medical services, such as doctors, physical therapists, or hospitals. The providers with a contract are “in network” and have agreed to a discounted fee. The insured person knows that the in-network provider agrees to accept the insurance company’s payment as full payment — subject to any co-payment or co-insurance, once the deductible has been met. Providers who have not entered into a contract with the patient’s insurance company may charge the consumer their full fee.  How much of the fee the insurance company pays depends on the insurance policy, and the patient is stuck with the balance.

Why surprise medical bills happen: The problem of “surprise” bills often arises when consumers go to a doctor or hospital that is in their network, but that hospital or doctor uses another provider who is not in the network. Frequently this happens when an out-of-network anesthesiologist assists an in-network surgeon at an in-network hospital, an out-of-network radiologist reads the X-ray, or an emergency department at the in-network hospital is staffed by a physicians’ group that is not in the network. In all of these cases, patients are ending up with bills they didn’t expect and over which they had no control. And they aren’t happy about it!

What UHCAN Ohio is doing about “surprise medical bills”: Consumers Union heard many stories from the people surveyed, and some of them are from Ohio. UHCAN Ohio and Ohio Consumers for Health Coverage (OCHC) are reaching out to those who gave their permission to be contacted to further develop the case for legislation in Ohio to address this problem. According to the Ohio Department of Insurance, the problem cannot be addressed by regulation alone without legislation. Recently, the state of New York passed a law that protects consumers in this situation while it sets up a process to resolve the payment issue between the provider and the consumer’s insurance company. 

The OCHC ACA Implementation team is developing a letter to send to Ohio lawmakers.  We have also put together a survey to get more information from Ohioans about the problems with surprise medical bills they have seen. If you would like to take the survey, you can do so by clicking here.  

How can you select a health plan or obtain services without knowing what providers are in the plans’ networks?

 Ohioans have complained about not being able to access the health care provider information they need to choose a health plan and not being able to confirm that a provider is in their network once they have enrolled in a health plan. That’s why Ohio Consumers for Health Coverage was initially pleased that the Ohio Department of Insurance published a draft rule on network disclosure. However, as we read through it, we also had some concerns, leading us to file written comments on both the first and second drafts of the rule (on Feb 20 and Mar 27^th respectively).

 Many provisions represent a step forward. The draft rule requires insurance plans to ensure that the format and content of a provider directory is not deceptive or misleading by complying with specific requirements. Insurers must update directories quarterly and within 15 days of getting notice that a provider is being added or leaving a plan or changing hospital affiliation. The rule also states that an enrollee shall not be required to enter an ID number to access the directory and defines “enrollee” broadly. It establishes certain reports that the Insurance Commissioner can request from insurance companies to measure compliance.

 However, OCHC made several recommendations to the first draft. We would like the review and updates to be more frequent. The rule states that the Commissioner “may” request certain data from the insurance company. We urged that “may” be changed to “shall” and that more extensive data be requested. 

 In the second draft of the rule, a provision was added that makes the reports filed by insurance companies confidential and not available to the public. OCHC protested strongly against that addition in its second comments. There is no purpose to be served by this lack of transparency.