Know before you go: How to make sure you don’t get hit with surprise doctor bills

By Jake Harris, WFAA
April 24, 2019

DALLAS — This week’s big story about people potentially being hit with huge medical bills following the split between Blue Cross Blue Shield of Texas and Texas Medicine Resources emergency room doctors caused a lot of viewers to wonder: Could this happen to me?

Health insurance is complicated enough, and not knowing if the facility you’re going to is in your network can just add to the stress. Luckily, there are ways to figure out how to go about making sure you know what you’re paying for at the doctor.

Here’s what to do, with tips from the Texas Department of Insurance (TDI).

First, check with your health insurance provider to see which facilities, doctors and procedures are covered under your health plan. You can do this either by going to the provider’s website or by calling your insurance provider through the number on your insurance card.

If you’re in a hospital, ask that you only be seen by doctors or specialists in your preferred network. If that’s not possible, ask for a clear understanding of how much the out of network doctors and procedures will cost you.

If you need to see a specialist, make sure you know if you need to get a referral before doing so. If you don’t know, call your provider and ask.

If you need your plan’s approval before you get a procedure done, make sure you get that approval, or you may have to pay that cost yourself. It always helps to double-check.
Know the difference between an emergency room, an urgent care center and a free-standing ER. Free-standing ERs are not attached to a hospital. Your health plan may not pay, or may only partially pay, for free-standing ER visits. Urgent care facilities, however, are a part of many insurer’s plans.

If you’re not sure what qualifies as an emergency visit or an urgent care visit, the Texas Department of Insurance classifies an emergency as

“…health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize a medical condition of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

(1) placing the person’s health in serious jeopardy;

(2) serious impairment to bodily functions;

(3) serious dysfunction of a bodily organ or part;

(4) serious disfigurement; or

(5) in the case of a pregnant woman, serious jeopardy to the health of the fetus.”

In addition, health plans must pay for care to stabilize your condition after an emergency, according to TDI. So, if you get emergency care at a facility outside your network, you may be transferred to a network hospital when your condition is stable.