Surprise Out-of-Network Billing: What to Do if You’re Billed for a Test Done at an Out-of-Network Lab

Imagine this scenario: You visit your doctor for a routine blood test, and your doctor’s office assures you that the test will be covered by your insurance. However, weeks later, you receive a bill for thousands of dollars from an out-of-network lab.

This situation is not uncommon, and it can be very frustrating. It’s known as “surprise out-of-network billing,” and it occurs when you receive a bill for medical services from a provider that is not in your insurance company’s network.

What is Surprise Out-of-Network Billing?

Under the Affordable Care Act (ACA), insurance companies are required to cover essential health benefits, such as blood tests and other diagnostic services. However, these benefits are only covered if you use in-network providers.

If you receive a bill for out-of-network services that should have been covered by your insurance, it’s important to understand your options.

What are My Options?

1. File an Appeal:

You can file an appeal with your insurance company. In your appeal, you should explain that you were led to believe that the lab was in-network and that you should not be responsible for the out-of-network charges.

2. Negotiate with the Lab:

You can try to negotiate with the lab to reduce the bill. You may be able to get a discount if you pay the bill in full or if you set up a payment plan.

3. Seek Help from a Patient Advocate:

A patient advocate can help you file an appeal, negotiate with the lab, and provide other support.

What should I do if Surprise Out-of-Network Billing Happens to Me?

If you receive a bill for surprise out-of-network billing, don’t panic. Follow these steps:

1. Contact your health plan and explain the situation. They may be able to help you resolve the issue.
2. Contact the provider that billed you and ask for an explanation.
3. File an appeal with your health plan if you believe the charges are incorrect.
4. Consider reaching out for help from a patient advocate or legal professional if you are unable to resolve the issue on your own.

How to Avoid Surprise Out-of-Network Billing

There are a few things you can do to help avoid surprise out-of-network billing:

1. Ask your provider if they are in-network with your insurance plan before you receive any services.
2. Check your insurance plan’s website to see which providers are in-network.
3. Call your insurance plan if you are unsure whether a particular provider is in-network.
4. Be aware of the rules regarding surprise out-of-network billing in your state.

If you are ever in doubt about whether a provider is in-network, it is always best to err on the side of caution and contact your insurance plan.