A large hospital bill after an emergency visit can make the painful time even more difficult, but according to experts, there are federal and state laws that protect people from overpaying for treatment.
“It can be overwhelming,” said JoAnn Volk, research professor at Georgetown University’s Center on Health Insurance Reforms. “Take a breath and figure out if something has been denied. You have options, and don’t take no for an answer.”
Mosaic spoke with Volk about navigating a hospital bill. Here is what she said.
Q: What should you do when you get your explanation of benefits from your insurer?
A: Your insurance company will send you an explanation of benefits, a breakdown of what the insurer is paying for the treatment and the amount you owe, either via mail or through your patient portal with what they covered. Check to see what has been covered or not.
Q: What should you do if coverage is denied?
A: If the explanation of benefits says that your insurance won’t cover anything, then federal law requires your insurance to tell you why they denied you care. You can appeal the denial with the help of your provider.
Q: If your appeal is denied, what should you do?
A: Under federal law, you can appeal the denial again and ask for an independent review of the insurer’s decision to see if they agree with the insurance company or if the treatment should have been covered and paid. This is a process that can often take months.
Q: What does a denial that says “failure to get prior authorization” mean?
A: Federal law says that you can’t require prior authorization for emergency services because, in an emergency medical situation, no one can stop and file paperwork for insurance companies to get permission to provide emergency treatment.
Q: If you go to an out-of-network hospital, can your insurance charge you more?
A: In emergencies, federal law requires insurers to charge the same for treatment received in-network and out-of-network hospitals for emergency services.
Q: Are insurance companies required to cover treatment for self-inflected injuries, like after a suicide attempt?
A: Under federal law, if your insurance company covers the treatment for an accidental injury they are required to cover the treatment for a self-inflected injury. So, if your insurance plan covers an emergency room visit, then your insurer cannot deny coverage if that visit was from a self-inflicted injury.
Q: What if my bills are more than I can pay, even if I have insurance?
A: Federal law requires nonprofit hospitals to provide people with assistance for their unpaid bills. Your hospital might have a financial assistance program that can reduce or eliminate out-of-pocket costs that are larger than what you can afford to pay. New Jersey requires all hospitals to provide this assistance for people based on income.
Q: What do you do if you are uninsured?
A: Hospitals must treat you and stabilize you regardless of insurance status under federal law. But after you are stabilized, they have no obligation to treat you, and you would not have coverage for the care you receive.
Stories by Amira Sweilem
Correction: This story has been corrected to reflect that insurance companies will send an explanation of benefits. Hospitals send bills.
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Amira Sweilem may be reached at asweilem@njadvancemedia.com.