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  • Javier Torres

Digital Health Solutions Disrupt Anxiety Surrounding Out of Network/Surprise Medical Bills

At the moment, Americans are living amid a global health crisis; fighting the spread of COVID-19. As the situation evolves, whether related to the current COVID-19 pandemic or an everyday emergency, when you require treatment, and/or hospitalization, navigating an already intimidating healthcare system can easily become stressful and demanding financially.


Annually, 99.6 million people receive surprise medical bills as high as $12,000, for treatment rendered that just so happened to be out of their covered network. Currently, 92% of Americans are insured, and with 73% of the population being serviced by what is referred to as narrow network plans, a type of insurance coverage with a smaller number of provider choices, the trend toward limiting options has led to an increase in out-of-network care. The most common of these circumstances is seen with visits to the ER where 20% of care provided results in at least one out-of-network claim. As Americans adapt to new realities caused by COVID-19, we are reminded that health care is costly.


Most insurance plans will remit reimbursement to patients for out-of-network claims. Following procedures with a provider outside of network coverage, the responsibility to file lies with the patient and can become quite an undertaking. Required information, not always readily available to patients, includes the National Provider Identification (NPI) number and Taxpayer Identification (TIN) number as well as the CPT/HCPCS billing code(s) and the ICD-10 diagnosis code(s) for the claim. In some situations, a narrative from the provider may be necessary. Adding more frustration, it can take 45 to 90 days even following a successful, manual claim submission, to receive money. Understandably, many patients get frustrated with how complicated the process can be and give up; never submitting their claim(s). Claim experts refer to this all too common outcome as the “shoebox effect.”


Innovative healthcare solutions are emerging and supplying tools designed to help patients and providers sail through the long, complex claim processes. Encouraging the healthcare industry to continue educating patients about the options available for both navigating within their health plan network(s) as well as getting reimbursed when they opt or are forced to go out-of-network is key. The priority must always be the patient experience and the wellbeing of America; the healthcare technology to simplify surprise/out-of-network billing is here and ready to work.


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