What is a surprise medical bill?
Balance billing—or a surprise medical bill—happens when you get a bill from a doctor, hospital, or other health care provider who isn’t part of your health plan’s network. Often, consumers didn’t know they were getting care from out-of-network providers.
For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the $600 that the health plan didn’t pay, as well as any copays, deductibles, and coinsurance.
I got a surprise bill. What can I do about it?
Call the doctor or provider that sent the bill and discuss your concerns. In most cases, Texas law requires providers to provide an itemized bill on request, so review the charges carefully. Some providers might accept a lower payment. You can compare the amount you were charged to the average market price using TDI’s Health Insurance Reimbursement Rates Consumer Information Guide or websites such as NewChoicehealth.com, FairHealthConsumer.org, and TxPricePoint.org.
Call TDI’s Consumer Help Line at (800) 252-3439 to discuss your options.