Investigative reporters from dozens of Tegna-owned TV stations interviewed patients who received a surprise medical bill within the past few years.
One of those patients is Heather Edwards. The 30-year-old mother of two pays more than $800 a month for health insurance.
In October, Edwards admitted herself into a hospital near Marble Falls, Texas after her 103 degree fever would not subside. According to her insurance provider, Humana, the emergency room was an in-network facility. A doctor determined she had a viral infection and gave her antibiotics. She later paid a small co-pay for the visit.
"I felt miserable. I felt like I got hit by bus," Edwards.
Three months later she received a surprise bill for $588. It was from the doctor who treated her, who wasn’t covered by Edwards’ insurance.
"I didn’t go in asking or thinking I’d have to ask the physician, the treating physician would be in my network. I really did not think that would be a question I would have to ask," said Edwards. "It’s very frustrating."
It happened to Anastasia Galinato too. The Chesapeake, Virginia resident says she was shocked when she got four separate bills for one outpatient procedure. Galinato ended up owing healthcare providers $3,480 for a five-hour hospital stay. She thought she asked all the right questions beforehand and was under the impression her procedure was all in-network. She learned after-the-fact, the anesthesiologist in the operating room was out-of-network.
“I was able to scrounge up a little bit extra every month so that I didn't have to take food from my kids' mouths, so that I didn't have to be stranded because there's no gas in the car, but not everybody has that luxury,” Galinato said.
Both patients are victims of what’s called surprise “balanced billing.” It typically happens when a patient goes to a hospital, covered by their insurance, but later learn the physician who treated them is out of their network. The patient is then responsible for paying the balance of the bill their insurance doesn’t pay. That’s why it’s called “balanced billing” and it’s all legal.
Stacy Pogue is a senior policy analyst at the Center for Public Policy Priorities in Austin, Texas. Last year, the bipartisan group found with some insurance companies, up to 50 percent of Texas Hospitals do not have one single doctor on staff covered by patients’ insurance.
"So, there's very little planning somebody can do in advance around an emergency. That's why we need good laws in place to protect consumers in emergencies,” said Pogue.
At least twenty-four states have some kind of limited protection to help consumers prevent or pay surprise medical bills. A Texas congressman, though, wants a federal law to make surprise billing illegal in all states.
In 2015, Congressman Lloyd Doggett of Texas authored the “End Surprise Billing Act.” If passed, it would prevent balanced billing during emergencies; provide 24-hour notice of out-of-network providers and require providers give consumers a cost estimate.
"[Patients] are going to an in-network hospital, they ought not to have to foot a bill that is the result of a conflict between hospitals, insurers and physicians," said Doggett.
Industry trade groups, like the American Hospital Association (AHA), would not say whether it supports Doggett’s bill. A spokesperson from AHA emailed to say the organization supports a “structured mediation model” to help consumers. Mediation helps consumers after they receive the surprise bill. It doesn’t prevent it.
AHA says it has also joined a taskforce called the Patient Financial Interactions Best Practices Project, a multi-stakeholder group of healthcare providers trying to improve billing transparency.
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