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Colorado Surprise Medical Bills - Know Your Rights and Consumer Tips
CoPIRG Foundation’s tips to protect yourself from surprise medical bills
Imagine you go to a hospital for a routine procedure. You’ve made sure your hospital and doctor are covered by your insurance. The procedure goes well and you head home to recover. Two weeks later, you get the bill, but instead of the copay you expected, you get a bill for nearly $4,000. Turns out, a surgical “assistant” who was out-of-network joined your in-network surgeon on your procedure and your insurance isn’t covering that bill as you expected. You’ve received a medical surprise bill and now owe the difference between what your insurance will pay the out-of-network surgical assistant and what you were billed.
What is a “surprise medical bill?
You receive a surprise medical bill when, through no fault of your own, you are treated by providers outside of your insurance network. These “out-of- network” providers can charge exorbitant rates only revealed when the surprise bill arrives. The average emergency room surprise bill is around $600, but these bills can range into the tens or even hundreds of thousands of dollars. When out-of-network providers charge these high rates, it drives up costs for everyone. Consumers are burdened with higher bills that they had no way of avoiding. And when insurers have to pay their share of this higher charge, they’re likely to pass on that cost to everyone by raising premiums.
Know your rights:
In Colorado, some patients are protected from surprise medical bills. It is important to know your rights to protect yourself from these bills. If you have insurance through Medicare, Health First Colorado, or are on Veterans Affairs Health Care, you are fully protected from surprise bills. This tip sheet is for people covered under any other type of insurance.
If your insurance plan is regulated by Colorado state law, you are protected from surprise bills in three situations:
- Emergency treatment by an out-of-network provider.
- Treatment by an out-of-network provider at an in-network facility without your consent.
- Emergency transportation by private out-of-network ground ambulances.
If your plan is state-regulated, the card will have “CO-DOI” printed on it. In these three situations listed above, you cannot be charged for anything more than what you would normally owe for in-network treatment. The out-of-network provider should not send you a bill. If you do receive one, you should not pay it. Follow the steps below on “How to fight a surprise bill,” and inform your insurer at once.
Exceptions to surprise billing protections
Colorado’s consumer protections against surprise medical bills do not apply to all patients and all situations.There are some exceptions. You could be required to pay an out-of-network bill in the following situations:
- If it is not an emergency situation and you purposely choose a provider or facility not within your insurance network.
- If your insurance plan is not a “state-regulated” plan - Colorado’s surprise billing protections only apply to insurance plans regulated by the state Division of Insurance. If your plan is state-regulated, the card will have “CO-DOI” printed on it. If you are still unsure whether your plan is state-regulated, contact your insurer. If your plan is not regulated by Colorado, see below to learn how you can try to lower your bill from providers not covered by your insurer.
- If you are transported by an out-of-network air ambulance.
- If you are transported by an out-of-network ground ambulance provided by a publicly funded fire agency. If you are unsure whether your ambulance was from a publicly funded fire agency, contact whoever sent you the bill and ask.
- If you receive nonemergency transportation (such as between two hospitals or between a hospital and a long-term care or rehabilitation facility) by any out-of-network ambulance.
How to prevent a surprise bill:
Because Colorado law does not protect everyone and every situation, there are a few steps you should take to prevent a surprise bill.
- Check with your insurer to make sure you are choosing a provider that is covered by your insurance. Make sure that the hospital or health care facility (lab, diagnostic center, surgery center) is in your insurance network before receiving treatment.
- When planning hospitalizations at an in-network facility, check with the facility to ensure that all providers (surgeons, anesthesiologists, surgical assistants, and others), lab services (such as blood work) and imaging services (such as X-rays, MRIs) are covered by your insurance plan. Be specific in requesting that all services you may need are covered by your insurer.
- Know where your nearest in-network emergency room is for those times when it is possible to choose.
Voluntarily choosing an out-of-network provider
If you have a health plan which has an out-of-network benefit, you can still choose an out-of-network provider. However, actively choosing an out-of-network provider will result in a higher copay and any additional costs your insurer will not cover.
Note: If you have to use an out-of-network provider at a facility covered by your insurance plan because there are no in-network providers available, you are only required to pay what you would normally pay for in-network services.
How to fight a surprise medical bill
- Make sure you are looking at an actual bill or invoice. An “Explanation of Benefits” is not a bill.
- If the first bill looks incorrect, do not pay it. Sometimes bills are sent before the insurance company has made its portion of the payment. Call your insurer and ask for more information.
- If you think you have received a surprise medical bill, you can use your rights to fight the charges. But first, be sure it is a bill covered by the consumer protections. Here are a few questions to ask. If you are able to answer yes to all of these questions, then you should not have to pay the bill:
- Is your plan state-regulated? If you are unsure whether your plan is state-regulated, you can call the Division of Insurance at 303-894-7499 or toll free outside of the Denver Metro Area at 800-930-3745.
- Is the bill for more than your typical copay for in-network services?
- If the bill is for a ground ambulance service, was the ambulance owned by a private company and used for emergency transportation?
- Is the bill for treatment in an emergency room?
- If the care was not in an emergency situation, was the facility in-network?
- If you were able to answer yes to these questions, it is likely that you have received a surprise medical bill that you are not required to pay.
- If you think the bill is illegal under state law, file a complaint with your insurer. Then file a complaint with the Division of Insurance online or at 303-894-7490. You should also file a complaint with the Colorado Division of Professions and Occupations Medical Board or at 303-894-7800. If you have already paid the bill, notify your provider that you want a refund. The provider is required to send you a refund within 60 days after you notify them.
- Sometimes the provider asks you to “assign your rights to appeal” to them, so they can fight the bill for you. You should seek advice before signing anything that would assign your appeals rights to someone else.
- If you need extra help, the Consumer Assistance Program at the Colorado Consumer Health Initiative is available to provide no cost assistance in helping you protect your rights. Call 303-839-1261 or https://cohealthinitiative.org/need-help/
If your medical bill does not meet all the requirements above to give you protections under the Colorado surprise billing law, you may still be able to lower the amount you owe. See below “Tips for lowering a medical bill.” Do your best to negotiate with the provider to avoid the bill from being sent to collections.
NOTE: If you purposely chose a provider who is not covered by your insurer, you may have waived your surprise billing rights.
Tips for lowering a medical bill
Ask for an itemized bill and check that you are not being mistakenly billed for treatment you did not receive.
- Compare the itemized bill to your Explanation of Benefits to see whether your insurer is paying its share. Sometimes patients are billed for services the insurer covers because their provider sent the wrong billing code to the insurer.
- Contact your provider and ask about anything you don’t understand.
- Contact your insurer to see if any mistakes were made on their end.
- If there are no mistakes, try negotiating with your provider. Many hospitals have patient advocate departments to help you negotiate the bill.
- Contact the Division of Insurance at 800-930-3745. They may be able to help you fight the bill if your complaint is against your insurer.
- Keep careful notes of all conversations you have. Get the names of the people you are speaking to. Keep your files in one place for easy access.
- Be patient and clear in your requests.
- If you are being harassed by debt collectors, learn more about your rights on the website of the Colorado Attorney General.
Special information during the COVID-19 pandemic
Testing for COVID-19 is free of charge for both insured and uninsured consumers if it is medically necessary. This means that if you have symptoms or have been exposed to someone with COVID-19 you can get a free test if you are referred by a provider. Even though testing is free, many people have been billed for other fees associated with the visit. Before being tested, contact your insurer to confirm the testing site is in-network and ask about cost-sharing. When you choose a testing site, call and ask about other fees.
In Colorado, you can also be tested at Walgreens, Walmart, eTrueNorth, and Health Mart at no cost. You do not need a referral to be tested at these pharmacies, but you will have to complete a questionnaire to determine that your test is medically necessary. To find out more about COVID testing in your state, use this resource.
Colorado has also declared that any COVID-19 treatment is considered emergency treatment, meaning it falls under the state’s surprise billing protections. As noted above, however, not everyone is protected by the state’s laws. Make sure to follow the steps above to avoid receiving a surprise bill.
More consumer protections are coming in January 2022
In a victory for consumers, Congress passed the No Surprises Act to expand surprise billing protections to all insured Americans. This means that the millions of Colorado residents on federally regulated plans who are currently without protections will be protected from surprise bills. The federal protections will closely mirror Colorado’s laws, protecting patients from surprise out-of-network bills for emergency treatment and non-emergency treatment at in-network hospitals. Under the new law, insured Colorado residents will also be protected from surprise bills for air ambulances. The No Surprises Act will not change ground ambulance laws, however, so it will still be important to know Colorado state law protections from ground ambulance surprise bills.
Last updated February 10th, 2021.
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