Understanding Surprise Billing Colorado and Your Rights

Surprise billing in Colorado can be a scary and confusing experience, but understanding your rights can help you navigate the situation with confidence.

In Colorado, surprise billing occurs when a healthcare provider or facility charges you for services that were not covered by your insurance plan. This can happen when you receive care from an out-of-network provider or facility, even if you didn't know they were out of network.

As a result, you may receive a surprise medical bill for thousands of dollars. In Colorado, this is known as a "balance billing." Balance billing is when a healthcare provider or facility charges you the difference between their billed amount and what your insurance company is willing to pay.

You have the right to dispute a surprise medical bill in Colorado. According to Colorado law, you can request an explanation of the charges and an adjustment to the bill if you believe it's incorrect.

Surprise billing occurs when a patient receives a medical bill from a provider who is not part of their insurance network.

This can happen when a patient receives emergency care or is treated by a specialist who is not part of their insurance network.

Patients may receive surprise bills from out-of-network providers even if they have a primary care physician who is in-network.

Surprise billing can be particularly stressful for patients who are already dealing with a medical emergency or unexpected illness.

In Colorado, surprise billing is a major concern due to the state's unique healthcare landscape.

In Colorado, you're protected from surprise medical bills if you receive emergency care at an out-of-network facility.

Surprise billing, also known as balance billing, can happen when you receive care from out-of-network providers or facilities, even if you're visiting an in-network hospital or ambulatory surgical center.

If you unknowingly receive care from an out-of-network provider at an in-network facility, you won't be balance billed unless you've given your prior written consent. This is a protection offered by Colorado law to state-regulated health insurance plans.

Here are the key protections against surprise medical bills in Colorado:

You might get a balance bill if you receive care from an out-of-network provider at an in-network facility. This can happen if someone on the surgical team, like an anesthesiologist or surgical assistant, is not part of your insurance plan's network.

You might also get a balance bill if you go to an emergency room that's in your network, but the doctor who takes care of you doesn't accept your insurance. You could be left with a surprise medical bill.

You shouldn't be charged more than your plan's copayments, coinsurance, and/or deductible, even if you receive care from an out-of-network provider. This is a protection against balance billing in certain situations.

You are protected from surprise medical bills in certain situations. If you receive emergency care at an out-of-network facility, Colorado law protects you from balance billing.

You can't be balance billed for unknowingly receiving care outside of your insurance network. Check your insurance card for "CO-DOI" to see if your health insurance plan is state-regulated in Colorado.

In-network facilities have rules to prevent surprise medical bills. If you receive services from an out-of-network provider at an in-network facility, you can't be balance billed unless you've given your prior written consent.

Here are some scenarios where you're protected:

In these situations, you should only be charged your plan's copayments, coinsurance, and/or deductible.

Colorado has laws in place to protect consumers from surprise medical bills. If you have a state-regulated health insurance plan, you're protected from being balance billed for out-of-network care.

You can contact the Colorado Department of Regulatory Agencies Division of Insurance for assistance with surprise bills. Reach them by phone at (800) 930-3745 or by email.

Surprise bills can occur in emergency situations or when receiving non-emergency surgical or ancillary services from an out-of-network provider at an in-network facility. This includes services from an out-of-network hospital, doctor, or other medical provider at a hospital.

If you're billed more than your payment responsibility, or if you believe you've been wrongly billed, you can file a complaint with the State Corporation Commission's (SCC) Bureau of Insurance. Contact the SCC at (877) 310-6560 or visit their website.

Colorado regulated health insurance plans, marked with "DOI" on the insurance card, must hold patients harmless when treated by out-of-network providers at an in-network facility, or in emergency situations. This means you'll only be charged the in-network rate.

For example, if you would have owed a $50 copay in-network, you won't owe more than $50 if your provider is unexpectedly out-of-network. If you have a Colorado regulated plan and receive a surprise balance bill, contact your insurance carrier and file a complaint with the Division of Insurance.

Here are some key Colorado laws and regulations to keep in mind:

Note that similar protections will apply to insurance plans not regulated by the Colorado DOI in 2022, but these protections are not yet in effect.

Understanding your medical bills can be a daunting task, but it's essential to tackle it head-on to avoid surprise medical bills. You should open and review all medical bills immediately.

To ensure you're getting accurate information, check if the document is a bill or an explanation of benefits. An explanation of benefits will clearly state "this is not a bill" somewhere visible.

If you're unsure about the bill, ask the entity billing you for an explanation of the charge. You're entitled to an itemized bill if you request one, and if you can't get one, file a complaint with the Colorado Division of Insurance.

A bill should clearly state who sent it and what services it's for. If the billed services don't match the services you received, you have the right to dispute the charge.

Here are some questions to ask yourself when reviewing your medical bill:

If you find an error or think you've been mistakenly balance billed, contact your insurer for clarification. Make sure they received a claim for the services you're being billed for, and ask if you're being held responsible for part of the bill or the entire amount.

If you're facing surprise billing in Colorado, it's essential to know when and how this applies. Surprise billing occurs when you receive a bill from an out-of-network provider or facility that isn't covered by your insurance.

You're only responsible for paying your share of the cost, like copayments, coinsurance, and deductible, if the provider or facility is out-of-network. Your health plan will cover any additional costs.

You have the right to dispute a bill if it's at least $400 more than your Good Faith Estimate. Make sure to save a copy or picture of your Good Faith Estimate.

Here are some key protections you have when balance billing isn't allowed:

If you think you've been wrongly billed, contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-985-3059 or visit their website at https://www.cms.gov/nosurprises/consumers for more information.