Total Rewards

Surprise Billing-What to Do and How to Prevent it

/ August 29, 2018 August 29, 2018

Surprise Bill

Surprise Bill- perhaps two of the most dreaded words in the English language, and unfortunately increasingly common in an age of out-of-whack medical billing practices. A rise in surprise emergency room bills and egregiously high out-of-network provider bills has propelled this issue into the spotlight, with national news provider Vox publishing a series of articles detailing the real life stories of people who have received highly inflated medical bills after visiting an emergency room. Statistics reported in the article “He went to an in-network emergency room. He still ended up with a $7,924 bill” by Sarah Kliff are staggering, including the Center for Public Policy Priorities’ estimate that at 18 percent of Texas hospitals there are zero in-network emergency room physicians for Blue Cross patients and for patients with Humana, this number increases to 63 percent of hospitals.

Let’s Break it Down

While it is easy to think that Texas is far away, or this will never happen to you, an increasing amount of denied emergency room claims have been crossing the desks of the claims resolution department at Exude as well. Usually these types of bills occur for one of two reasons. The first occur during a true emergency when patients are not in a fit state to dictate where they would like to be taken to receive medical attention and end up at an out-of-network facility. The second occurs when a patient chooses an in-network facility, but is seen by a physician who is out of network. It is also worth mentioning that these types of bills can occur in non-emergency situations as well. It’s fairly common for a patient to go in for a routine surgery or procedure with an in-network provider and facility, and end up with a large bill for an out-of-network anesthesiologist. Receiving a bill for thousands of dollars may feel like an impossible burden to lift, but all hope is not lost. There are many ways to prevent these types of situations and navigate through them if avoidance is impossible. Here are some tips and tricks for dealing with a surprise bill.

Prepare Ahead of Time

Have a Game Plan

It’s always good to plan in advance, especially for emergencies. Take some time to research hospitals in your area and learn which participate with your insurance provider. When you are making a selection, dig a little deeper and also check some of the emergency room doctors who practice at the facility to make sure they are in-network as well. Once you find one that meets all your criteria, communicate your choice to your “emergency contacts” or those who are likely to be around during an emergency. You can even put a note in your wallet stating which hospital you would like to be taken to in case a stranger or EMT has to make the decision of where to take you.

Download Carrier Apps

Most carriers offer a member app that gives you access to a slew of things, including easy access to searching for in-network providers. This may come in handy in lesser emergency situations, like a broken bone or stitches. You can also use it when you are in the emergency room and want to check and make sure the doctor attending to you is in-network.

Call Exude

If you are a benefits client of Exude and have a procedure that was planned in advance, make sure to send over your physician’s name and facility before the procedure so your Client Care Specialist can confirm that all your providers are in-network. If you send over the procedure codes, they can confirm if and how the services you will be receiving are covered. Don’t forget that Exude offers a 24-hour On Call service as well, so if you have an emergency after hours and do not have access to a list of participating providers, you can reach out at any time and receive assistance from an Exude employee.


Knowledge is power, and the same goes for understanding how your health insurance works. Make sure you understand how your insurance covers things like emergency room visits. Does your plan require you to pay a co-pay upfront or should you expect a bill to come in the mail? What is a co-pay anyways? If you are an Exude benefits client, these are they types of things your Client Care Specialist would be happy to discuss with you! Once you are confident in how your insurance works, you are more likely to notice billing errors or speak up if a balance or billing procedure does not seem correct.

It’s not too Late to Take Action!

Know Your Rights

While legal protection from surprise bills is still limited in the US, 6 states offer comprehensive protection from surprise bills. These types of laws protect consumers by holding them harmless from extra provider charges and prohibiting providers from balance billing. They also provide guidelines for adequate payment standards and dispute resolution processes. States that offer these protections include California, Connecticut, Florida, Illinois, Maryland and New York. There are 15 other states, including Pennsylvania, that offer limited protection to consumers, like hold harmless laws that apply in select situations. If you are currently holding a surprise bill in your hand, look into what type of legal protection your state might offer you!

Don’t Procrastinate

The final and most important thing to remember if you receive a surprise bill is to act quickly. There is usually a time limit for reversing claims, so you do not want to put off resolving a billing discrepancy. It’s much harder to get a claim fixed if you are working outside of the timely filing deadline and your legal protection may have a deadline as well. If Exude is your benefits broker, send that unexpected hospital bill over to your Client Care Specialist and save yourself the headache of spending long hours on the phone in order to get your bill covered.