Surprise Medical Billing

If you get care outside your insurance network without knowing, federal and Colorado laws protect you. This includes emergency care at a hospital not in your network or seeing a doctor who's out-of-network at an in-network facility. You won’t face "surprise" bills in these cases.

Surprise billing, also called balance billing, happens when you get an unexpected bill for the difference between what your insurance pays and the total cost. This can happen if you get emergency care from a hospital or doctor outside your network. It can also occur if you visit an in-network facility but see a doctor who isn't in your plan.

In 2019, Colorado passed a law. This law protects people in Colorado with state-regulated health insurance. Now, people won't get surprise bills if they receive care outside their network without knowing. To see if your plan is state-regulated, check your insurance card for "CO-DOI".

If the law applies to your health insurance plan:

• You generally cannot be balance billed for unexpected out-of-network care unless you agreed to it in writing.
• You are only responsible for your normal in-network costs, including copays, deductibles and coinsurance.
• If you choose to get care from a doctor or hospital that's not in your network, you're responsible for the full cost.
• Just because you get a notice about this doesn't mean you're giving up your rights under Colorado law Sections 10-16-704(3) or (5.5), C.R.S., or your rights to benefits under your health insurance plan.

When you see a doctor, you might have to pay some costs out of pocket, like a copay, deductible or coinsurance. If you see a doctor or go to a hospital that's not in your network, you might have to pay more or even the full bill.

Out-of-network means a doctor or facility that hasn't agreed to work with your insurance plan. They might bill you for the difference between what your insurance pays and the full cost. This is called balance billing, and it's usually more than what you'd pay if you saw a doctor in your network.

Surprise billing is when you get a balance bill that you didn't expect. This can happen if you get emergency care from a hospital or doctor who's not in your network, or if you go to a hospital that's in your network but are treated by a doctor who's not.

1. Emergency Care

If you receive emergency services from an out-of-network provider or facility:

• You cannot be balance billed.
• You only pay your in-network cost-sharing amount.

These protections may also apply to services you receive after you are stabilized unless you agree in writing to waive your protections.

2. Certain Services at an In-Network Facility

Even if you visit an in-network hospital or surgical center, some specialists may not be in your insurance network. You are still protected from balance billing for services such as:

• Emergency medicine
• Anesthesiology
• Pathology
• Radiology
• Laboratory
• Neonatology
• Assistant surgeons
• Hospitalists
• Intensivists

For these services, providers cannot balance bill you and cannot ask you to waive your protections.

• You only pay your share of the cost, which is based on what you would pay if the doctor or hospital was in your network. Your insurance plan pays the rest directly to the doctor or hospital.
• Hospitals and some other providers have to give you a notice that tells you about your rights and asks if you want to see a doctor who's in your network. They must also tell you if a provider may be out-of-network.

Your insurance plan generally must:

• Cover emergency care without requiring approval first (also called prior authorization)
• Cover emergency care from doctors who aren't in your network
• Base what you owe on what it would pay a doctor or facility in your network
• Count what you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit

If you think you’ve been incorrectly billed for out-of-network charges, reach out to the CU Medicine billing department. You can email us at BillingQuestions@cumedicine.us or call 303-493-7700.

For details about your rights under Colorado law, check the Colorado Department of Regulatory Agencies Division of Insurance website.

For more on your rights under federal law, check the Centers for Medicare & Medicaid Services website.