If you have been to the hospital recently and received a ‘surprise bill” after you thought that your insurance provider had paid all claims…then you probably learned the hard way about ‘balance billing’.
According to healthcare.gov - Balance Billing.” When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.”
Note: The above simplified explanation does not address the issue of when an out-of-network physician gives treatment in an emergency room situation.
Another definition: Balance billing, sometimes also called ‘extra billing’, is the practice of a healthcare provider billing a patient for the difference between what the patient's health insurance chooses to reimburse and what the provider chooses to charge.
According to a blog by Ashley Noble –titled: States Tackling Balance Billing Issues in National Conference of State Legislatures (www.ncsl.org) …
“ The authors found 21 states have laws on the books that provide some amount of consumer protection from balance and surprise bills in emergency departments and in-network hospitals. Of these states, The Commonwealth Fund identified six states with “comprehensive protections,” including California, Connecticut, Florida, Illinois, Maryland and New York.”
You can read the complete article in The Commonwealth Fund.org abstract titled: Balance Billing by Health Care Providers: Assessing Consumer Protections Across States (June 13, 2017) by Kevin Lucia, Jack Hoadley, and Ashley Williams
Balance billing can occur in emergency room situations as well as emergency transport such as air ambulance. As Ms. Noble notes- “During an emergency, it isn’t reasonable to expect people to ensure that the ambulance service that will be transporting them to a hospital emergency department is a provider within their insurance carrier’s network. This is particularly so when the nearest ER may be hundreds of miles away.”
Balance billing refers to a physician's ability to charge the patient any outstanding balance after an insurance company submits its portion of the bill. Out-of-network physicians, not bound by contractual, in-network rate agreements, may bill patients for the entire remaining balance.
The practice (of balance billing) has become startlingly more frequent. In 2018, according to a University of Chicago survey, 57 percent of American adults were affected by a surprise bill for care that they thought was covered by insurance.
More patients are receiving surprise billing as consumers turn to specialty hospitals; cancer centers and children’s hospitals for treatment. Also, many hospitals now “contract out” the emergency room services.
According to the National Academy of State Health Policy (NASHP.org) “ Surprise balance bills occur when patients receive unanticipated charges for health care services because they were unaware that care was delivered by an out-of-network provider or facility. In some cases, surprise balance bills can amount to hundreds if not thousands of dollars in medical expenses.”
For a recent NASHP article (March 19,2019) outlining how some states are dealing with the issue, go to the website for the article – Highlights of States’ ‘Surprise’ Medical Balance Billing Laws.
It is beyond the scope of this article to determine each case where balance billing should not have been applied.
As always, if you receive a “surprise bill” – do not disregard or ignore the bill. Contact the sender and discuss the terms of the bill to determine what action is appropriate.
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