PERALTA, KEANU GYBS C.

BSN IV-C

Some patient's health insurance company pays a health care provider less than the
amount charged for the service provided. Because the health service providers have not
agreed upon payment through a contract, the health service provider bills client for the
remainder of the costs. This is called a "surprise billing".

1. Identify two situations why "surprise billing" happens between a client and the health
care provider?

a. Surprise billing happens when people unknowingly get care from providers that are
outside of their health plan's network and can happen for both emergency and non-
emergency care. For example, A patient goes into an emergency room at an in-network
hospital and, unable to quiz providers on who is in-network, receives care from an out-of-
network anesthesiologist. Later, the patient receives a costly bill for out-of-network care.

b. The fees anesthesiologists and emergency medicine providers charge to commercial

insurers are approximately five times greater than Medicare pays for equivalent services.

2. Identify two ways on how you can address this "surprise billing".

a. When planning hospitalizations at an in-network facility, check with the facility to

ensure that all providers (surgeons, anesthesiologists, and others), lab services (such as
blood work) and imaging services (such as X-rays and MRIs) are covered by your
insurance plan. Be specific in requesting that all services you may need are covered by
your insurer.

b. Beware of “facility fees." Hospitals and other large health facilities often add a charge
for the use of their space and equipment. When the situation is not an emergency, ask if
there will be a facility fee. If so, find out whether the procedure can be done at another
location that doesn’t charge a fee. Facility fees can be tough to fight after the fact.