Can a doctor or hospital bill you for an expensive medical procedure that they never confirmed with your insurance company?

Generally, in the United States, a doctor or hospital cannot bill you for an expensive medical procedure that they never confirmed with your insurance company. Here's an overview of how medical billing and insurance work:

1. Estimation and Pre-Authorization:

- When you undergo a medical procedure, your healthcare provider (doctor, hospital, etc.) estimates the cost of the procedure and any additional services associated with it.

- In many cases, they provide this information to your insurance company (if you have insurance coverage) for pre-authorization or preapproval. This step is crucial to verify whether your insurance will cover the procedure and to determine your financial responsibility, such as copayments, coinsurance, or deductibles.

2. Consent and Billing:

- Before the medical procedure, you will likely sign consent forms acknowledging the estimated charges and any expected out-of-pocket expenses.

- The healthcare provider will then perform the procedure and send a bill to both you and your insurance company for payment.

3. Insurance Coverage:

- Your insurance company will review the medical claims submitted by the healthcare provider. If they find the procedure and charges appropriate and in line with your coverage, they will process the claim and may send a payment directly to the healthcare provider or reimburse you directly (depending on your insurance plan and policy).

4. Financial Responsibility:

- If the healthcare provider did not confirm your insurance coverage or pre-authorize the procedure, and you are later billed for expenses that were not covered by your insurance, you have the right to dispute the charges with both your insurance company and the healthcare provider.

- You may request medical records, bills, and statements to substantiate the charges and communicate your concerns to the billing department of the provider.

If you receive a bill for a procedure that was not preauthorized or is covered by your insurance, it's important to take action promptly to resolve the issue:

1. Contact your insurance company and inquire about your coverage for the procedure in question. Obtain a written response or clarification from them.

2. Reach out to the healthcare provider's billing department and explain the situation. Provide any relevant documentation or correspondence from your insurance company.

3. If the matter remains unresolved, you can file a complaint with your state's insurance department or the appropriate regulatory body overseeing medical billing practices.

4. Review your Explanation of Benefits (EOB) from your insurance company to ensure that the charges reflect the actual expenses and align with your coverage.

Remember to keep records of all your communication and documentation related to the medical procedure and the billing issue to support your case.