Surprise bills have gotten a lot of press recently. It’s been all over the media. Surprise bills have been occurring for a long time and usually come in the form of network providers being utilized in what is believed to be a traditional PPO setting, but non network providers are engaged.. In other words, someone goes to a PPO network hospital, yet the anesthesiologist, the surgeon, the radiologist, and other providers are not part of the PPO network, hence there are huge surprise non-network bills sent to the patient unexpectedly.

Here’s a big surprise bill for you! Last summer (2018) there was a jury trial in Colorado regarding a surprise bill. Several years prior, a patient went to a hospital for surgery and was told that that their out of pocket expense was going to be about $1,800. After three nights in the hospital the bill ended up being over $300,000!

An audit of the bill was performed, and payment was made to the hospital of approximately $74,000+. The hospital subsequently chose to go after the patient for the >$235,000 balance. Can you imagine the surprise bill to the patient?

The outcome of the jury trial was that the $74,000+ payment was deemed to represent a fair and reasonable profit to the hospital, and the hospital could not balance bill the patient.

The hospital’s case rested on the fact that the patient had signed a document stating that they would be responsible for whatever the insurance did not cover, yet there was nothing written in that document as to what the financial obligation would be that the patient would be responsible for. The patient’s insurance defense was that the hospital should be paid a fair and reasonable profit, not an egregious surprise bill for  excessive charges.

The case is being appealed by the hospital and the decision should come before the end of the year, but this will be a monumental court case in Colorado and a precedent for another states as well.

If you’d like to learn more about how your insurance can pay facilities a fair and reasonable profit, as opposed to a phantom PPO discount off of egregious pricing, give me a call or send me an email and we can chat.

frank.stichter@strategichpc.com                                  970-349-7707