What is surprise medical billing? What are the proposals to fix this issue?

Updated on August 27, 2019

Surprise medical bill or balance billing occurs when you receive a bill from your healthcare provider, who isn’t part of your network. In order to grasp the concept fully we’ll give you a simple example. For instance you go to an in-network hospital for some treatment, but you get treated by an out network doctor. Your insurance plan and your health care provide may agree on an adequate amount of reimbursement. But your doctor can bill you for things the insurance won’t reimburse and hence, you get billed.

Medical billing companies have observed that Patients receive a steep financial hit after receiving treatment from out of the network health care providers. Many political parties are aiming to present a proper proposal in order to protect patients from receiving steep bills. A legislation is on way to rectify surprise medical billing.


Do a research on your preventive care coverage and billing codes.

Even though many insurance health plans cover up to 100% of preventive care. But sometimes new technologies can result in a surprise bill. Therefore before any medical visit, call your insurer in order to find out which specific screening tests are covered and get their billing codes. 

When you visit, confirm the tests and procedures that will be performed and verify the billing codes against the ones provided by your insurance. If the codes do not match, ask your doctor.

Ask your doctor to use in-network facilities for tests and procedures.

Out of network facilities can also cost you more, just like an out of the network doctor. Therefore, when your doctor orders a test, be very clear you want to stay in-network. You can call your insurer, they will help you find nearby in-network labs.

Some insurance providers are rewarding it’s users for using in network labs. Switching to in network labs earns you some points, the more you earn points the more gifts you receive.

Look around for the best price available on tests and procedures.

The cost of a blood test may vary very much within an area. If you know the billing code of your blood test, you can look up for the prices on the health care checking websites in order to compare the costs within your area. You should focus on the actual cost itself rather than the average.

The price of an MRI scan can range from as low as 300 dollars to 6000 dollars all in the same locality. Therefore it is highly recommended to look out for the best optimal price for your test or procedure which suits your needs.

Watch out for “facility fees”

Most hospitals and large facilities usually add a charge for the use of their space and equipment. Sometimes a simple bandage and some anti-biotic ointment in the emergency ward can amount to a few hundred dollars, because of the facility fees.

Ask your insurer, if there will be a facility fees. If yes, ask whether this test or procedure can be performed on another location that doesn’t charge facility fees.

Prepare yourself in case of an accident; know more about your local ambulances.

Ambulances can cost you a few thousand dollars for just a few miles. You can check from your local fire department and ask which ambulances operate with in your area. Then find out whether they are in network or not. In case, you have to face an out of the network ambulance charge, try negotiating with the ambulance service or your insurer to reduce the fee.

You can also be charged for an ambulance fee while transferring from on hospital to another. If you face such situation, ask your insurer which ambulance services are available and whether they are in network or not. You may be able to reduce your transportation cost by using an in network ambulance.

Know your rights regarding surprise billing

Many states offer patients protection against balance billing. In serious cases of surprise billings state authorities have given outright bans to healthcare providers. In other cases hospitals are forced to achieve transparency in their methods and ensure proper dispute resolution procedures.

If you find yourself surprise billed for any medical treatment, seek the hospital billing manager and negotiate with the manager or the doctor to waive or lower their fees. You can also seek the advice of your insurer.


Surprise billing is a big problem identified by legislators and medical billing companies, and patients deserve protection by law. Aside from getting information regarding tests and procedures, let your doctors know if you have any financial concerns and ask for cost estimates for the specified procedures. One should be diligent before going in for medical procedures.

The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.