For Consumers

Surprise billing stories

The following are samples of consumer complaints filed with the Office of the Insurance Commissioner since 2014. The cases and locations are real, but the names have been changed and some details omitted to protect individual health information.

Dana’s story

Dana, of Yakima County, was taken by her husband to the emergency room at a regional hospital. During her stay, six different doctors treated her. Her husband chose the hospital because it was an in-network facility for her insurance plan. She and her husband were never informed that the doctor assigned to her was not in her insurance network. The insurer paid nearly $1,000 to the providers (in addition to $19,839 for the hospital bill), and asked the providers to accept the allowed amount as payment in full or at least offer a discount.

Dana already paid her $3,300 maximum out-of-pocket costs. Surprise billing cost her an extra $4,713.

Gene’s story

Gene, of Grays Harbor County, was referred to a hospital in Olympia by his doctor. He had an individual plan with a $3,000 deductible and 20 percent co-insurance. Treatment for his condition resulted in two charges from a non-network provider. He paid $108 in deductibles for the two bills, but received charges from out-of-network providers.

Gene paid $108 in co-pays and met his deductible. Surprise billing cost him an extra $3,238.

Karla’s story

Karla, of Thurston County, went to the emergency room at an Olympia hospital. The bill was $3,415. Her insurance covered 90 percent of the allowed amount ($2,177) for the hospital, leaving her responsible for a $150 copayment and $203 co-insurance. The provider’s bill was $1,040. The allowed insurance amount was $379 and covered at 90 percent, leaving Karla responsible for $38. She was also balance billed for $661 (the amount over the allowed amount).

Karla paid $391 in co-pays and met her deductible. Surprise billing cost her an extra $1,052.

Bob’s story

Bob, of Clark County, was advised by his doctor to go immediately to a local hospital emergency room for a life-threatening condition. Bob received misinformation that the hospital was a preferred provider for his health plan. However, the hospital and provider group were not in-network for his plan. The hospital bill was $3,622, though the allowed insurance amount was $2,536. Because Bob’s emergency benefit is a $250 co-pay, then deductible, then 20 percent co-insurance, he was responsible for his $250 co-pay and then $2,286 for his deductible. The hospital could have balance billed him for $1,087, the amount in excess of the allowed amount, but it decided to write it off. However, a medical specialist billed him $932. Bob’s insurer allowed $221.

Bob paid $2,756 out-of-pocket costs. Surprise billing cost him an additional $711.

Dave’s story

Dave, of Thurston County, went to the emergency room at an Olympia hospital for a life-threatening heart condition. While the hospital was in network, the providers were out of network. Dave’s insurance allowed $231 (of a $1,650 bill) and that was applied toward his deductible. He also had to pay $704 for the hospital charges because his deductible had not been met.

Dave paid $935 in out-of-pockets costs. Surprise billing cost him an additional $1,419.

Amy’s story

Amy, of Eastern Washington, was in an automobile accident. She went to a regional hospital emergency room for a checkup. The hospital determined she had coverage but never informed her that the providers staffing the ER were out of network. The providers at the time were in the middle of negotiations with an insurance company, but those were not yet completed. Amy learned about the out-of-network providers weeks later when her claim was denied.

Amy already had paid $1,126 in out-of-pocket costs. Surprise billing cost her an additional $1,387.

Tell us your story

If you've had a surprise medical bill, we'd like to hear from you. Please send us an email with your story.