Big Surprises Come in Tiny Packages

We have all heard about it—maybe it has even happened to you. After in-network hospital services, a statement arrives in the mail with an unexpected self-pay balance.

There are unknown charges on your statement and your insurance company has denied them for out-of-network services.

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. These can include anesthesiologists, radiologists, pathologists, surgical assistants and others.


Who doesn’t like surprises? When they come in the form of surprise medical billing, they can have a negative impact on the patient, the physician and the healthcare facility/hospital providing the service.

I have been doing some reading on the world wide web in relation to this—here are my thoughts and possible solutions:

The Hospital

Hospitals are turning to third-party companies to find doctors to fill vacancies at a much faster pace for a lower cost. In some cases, these doctors are contracted through staffing services who offer profit-sharing agreements with the hospital and are out-of-network.

This might be saving the hospital money, however patient satisfaction will most likely decline when patients receive surprise medical bills from their trusted in-network hospital.

Entire departments within a hospital facility can also be contracted out-of-network.

For instance, a NICU department within your in-network hospital might be contracting with a physician’s group that does not accept your insurance. There are a number of stories circulating lately of entire NICU charges being billed and denied as non-covered because they are out-of network.

In the end, the patient ends up with a hefty medical bill they were not expecting from their in-network-hospital.

The Physician

Physician groups continue to form and are able to stay out of insurance networks and levy high bills on unsuspecting patients. In most cases, this is happening in emergency rooms with ancillary doctors and anesthesiologists where the patient does not have the ability to choose.

On average, 18% of Emergency Department Visits Result in at Least One Surprise Bill.


Patients that arrive by ambulance or are unresponsive also tend to get hit with surprise medical bills. The Affordable Care Act (ACA) provides partial protection for patients receiving out-of-network emergency care. It does not, however, prohibit balance billing.

With surprise medical billing becoming more prevalent and laws starting to make their way through congressional legislation, physician groups may be feeling some push-back. More and more patients are stepping up and appealing surprise medical bills and in some cases, billed charges are being reversed.

It makes sense now more than ever for physician groups to start joining with the in-network insurance companies and their rates.

Protecting Provider and Patient Relationships

Hospitals can provide patient advocates in-house to educate patients on in-network and out-of-network services. This would help alleviate any mistrust between patients and providers, and increase patient satisfaction.

Hospital educators can provide insight to hospitals on issues that arise from surprise medical billing. If hospitals are more aware of the effects surprise medical billing is having on their patients, we might see more systems put into place to decrease the number of surprise medical bills.

Prior to a service, if the patient is able, they should request in-network physicians only.

Removing the patient from the equation might be necessary. If this is truly about the patient, out-of-network physician groups should be working directly with health insurance companies, charging and covering at the in-network rates to reduce such surprises.

Katie Peterson, CPAR
Operations Manager-Denial Solutions

Katie holds 17 years of revenue cycle experience, ranging from hospital pre-registration to insurance claim resolution. Her knowledge spans a variety of topics, including insurance verification, prior authorizations, coding verification, claim editing and submissions and insurance denials.
She is a strong believer in success by collaboration and teamwork, and actively participates on Nemadji’s advisory and innovation teams. Katie enjoys attending AAHAM events both locally and nationally, and looks forward to continuing to build relationships that support growth for both members and providers.

Katie is passionate about helping providers understand the complexities surrounding denials—both preventing and overturning—and was a key player in developing Nemadji’s new denial management solution, Resolve.

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