Know Your Rights
What is surprise billing?
Surprise medical billing is when an insured patient gets a balance bill they didn’t expect.
Why does it happen?
It can happen when you get care from a provider or a facility that is not in your insurance network. This can happen when you have emergency care at an out-of-network hospital or when you go to an in-network facility but you’re treated by someone there who is not part of your network.
It helps to understand what’s meant by a “surprise” or “balance” bill.
When a facility or provider is out-of-network, it means they haven’t signed a contract with your health plan. These providers sometimes try to bill you for the difference between what your plan agreed to pay and the full amount they charged for a service. This is called “balance billing.” Simply put, they want you to pay the balance of the bill.
This amount is often more than what you would pay in-network and might not count toward your annual out-of-pocket limit. Patients are often very surprised by these bills.
If I get a surprise bill, do I have to pay it?
There are some types of balance bills that are not allowed by federal and state law. It’s important that you know which ones they are.
You don’t have to pay if:
- You went to an out-of-network hospital for emergency This includes care you got after you were stable, unless you give written consent and give up your protections not to be balance billed once your condition was stable.
- You went to an in-network facility or ambulatory surgical center, but had an out-of network provider for:
- emergency medicine or anesthesia
- pathology, radiology, or labs
- assistant surgeon, hospitalist, or intensivist services.
- These providers may not ask you to give up your protections to be balance billed.
- You went to an in-network facility or ambulatory surgical center, but had an out-of-network provider for any other out-of network services you got while you were there (unless you gave written consent to give up your protections against balance bills).
When balance bills are not allowed, you can only be charged the amount you would pay in-network.
When balance billing is not allowed, you’re still responsible for any costs you usually pay (copays, coinsurance, and deductibles). But your insurance pays the rest and will pay the provider and facilities directly.
When balance bills are not allowed, your health plan is required to:
- Cover the emergency services you get without asking for pre-authorization.
- Base your bill on their in-network costs and show those costs in your explanation of
- Count what you pay toward your deductible and out-of-pocket limit.
What should I do if I think I’ve been wrongly billed?
Contact the facility billing office and review the bill with a billing specialist.
If you think you’ve been wrongly billed, you may file a complaint with the federal government or the Tennessee Department of Health.
Call West Tennessee Bone & Joint Clinic Billing Department at 731-410-2305 and ask to speak to a Billing Insurance Specialist.
- To file a complaint with the federal government:
- go to CMS.gov/nosurprises/consumers
- or call (800) 985-3059.
- To file a complaint with the Tennessee Department of Health:
- go to TN.gov
- or call (877) 287-0010.
Go to CMS.gov/nosurprises/consumers to learn more about your rights under federal law.
Know your rights
You’re never required to give up your protections from balance billing.
You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network