Five Facts About Surprise Medical Bills

Surprise medical bills have troubled Americans for years. As COVID-19 spreads, lawmakers seek remedies.

  1. About 1 in 5 elective surgeries results in surprise bills.

A study of 347,356 elective surgeries found that 20 percent of insured patients received unexpected bills even though they chose in-network primary surgeons and facilities. It said surprise charges can occur “if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians.” Insurance plans often allow considerably higher charges by providers outside their preferred “networks.” The study was reported in JAMA Network, an affiliate of the Journal of the American Medical Association.

  1. Surprise bills also come from emergency and inpatient care.

In roughly 1 of every 6 emergency room visits and inpatient hospital stays in 2017, “patients came home with at least one out-of-network medical bill,” an analysis by the Kaiser Family Foundation concluded. The report said “18 percent of all emergency visits and 16 percent of in-network hospital stays had at least one out-of-network charge, leaving patients at risk for surprise medical bills.”

  1. Surprise bills vary greatly state to state.

The Kaiser study found that surprise medical charges for emergency and inpatient treatments are far more frequent in some states than others. “For instance, emergency care visits were more likely to result in at least one out-of-network charge in Texas, New Mexico, New York, California and Kansas, and less likely in Minnesota, South Dakota, Nebraska, Alabama and Mississippi,” it said. Several states have passed laws trying to address the problem. However, the Kaiser study says, because of limits imposed by federal law, “people with large employer coverage generally are not protected by state surprise-billing laws if their plan is self-insured.”

  1. Doctors send more surprise bills than do hospitals.

Most of the potential surprise out-of-network emergency charges found in the KFF study “were from doctors and other out-of-network professionals, rather than from the hospital or emergency facility.” It said inpatient surprise bills can occur “because the doctors who work in hospitals often do not work for the hospitals; rather they bill patients separately and may not participate in the same health plan networks that cover the in-network facility.”

  1. A senator/physician is among those trying to stop surprise medical bills.

Several congressional proposals would address surprise medical bills. A bipartisan bill, co-sponsored by Sen. Bill Cassidy (R-LA), a physician, would limit such charges on several fronts. For emergency care, it “would ensure that a patient is only required to pay the in-network cost-sharing amount required by their health plan for emergency services, regardless of them being treated at an out-of-network facility or by an out-of-network provider.” Also, it would “protect patients who require additional health care services after receiving emergency care at an out-of-network facility, but cannot be moved without medical transport from the out-of-network facility.” And for non-emergency care performed by an out-of-network provider at an in-network facility, the legislation “would ensure that patients owe no more than their in-network cost sharing in the case of a non-emergency service that is provided by an out-of-network provider at an in-network facility.”


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