Can an In-Network Provider Balance Bill?

Medical bills can be a source of confusion, especially when unexpected charges appear. Balance billing, a practice that often bewilders patients, occurs when individuals receive services from a provider they believe is covered by their insurance, only to find themselves responsible for a larger portion of the bill than anticipated. This article clarifies when in-network providers can issue these additional charges, which is important for managing healthcare costs effectively.

Understanding Key Terms

Balance billing occurs when a healthcare provider bills a patient for the difference between the amount the provider charged for a service and the amount the patient’s insurance plan paid. This charge is distinct from typical out-of-pocket costs like deductibles, copayments, or coinsurance, which are the patient’s agreed-upon share of the cost for covered services.

An in-network provider is a healthcare professional or facility with a contractual agreement with a specific health insurance plan. This contract establishes negotiated rates for services provided to plan members. The provider typically agrees to accept these negotiated rates as full payment for covered services, minus patient cost-sharing responsibilities.

Contracted rates are the pre-agreed prices for medical services between an insurance company and an in-network provider. This agreement ensures the provider will not charge the patient more than this negotiated rate for covered services, beyond the patient’s deductible, copayment, or coinsurance amounts.

General Rules for In-Network Providers

An in-network provider generally cannot balance bill a patient. This is because their contractual agreement with the insurance company typically stipulates the provider accepts the negotiated rate as full payment for covered services. The patient’s financial responsibility is limited to their specific cost-sharing amounts, such as deductibles, copayments, and coinsurance.

For example, if a service costs $500, the insurance company’s negotiated rate is $300, and the patient has a $50 copayment, the provider accepts the $250 from the insurer plus the $50 copayment from the patient as full payment. The remaining $200 difference between the initial charge and the negotiated rate is typically written off by the provider.

Specific Situations Where Balance Billing May Apply

Despite the general rule, a patient might receive a bill for more than their expected cost-sharing, even from an in-network provider. This occurs if services are not covered by the patient’s insurance plan. For example, if a service, such as a cosmetic procedure, an experimental treatment, or a service deemed not medically necessary, is explicitly excluded from coverage, the in-network provider can bill the patient for the full cost. This is permissible only if the patient was informed beforehand and typically provided consent to receive and pay for the non-covered service.

Another situation arises when services exceed the limits set by the patient’s insurance plan. Some health plans have limitations on the number of visits or specific types of services they will cover within a given period. If a patient continues to receive services beyond these defined limits, the in-network provider may bill the patient directly for the additional services.

Balance billing can also occur if a patient knowingly chooses an out-of-network service or provider within an otherwise in-network facility and signs a consent form. This might happen if a patient specifically requests a particular specialist not contracted with their plan, even if the hospital where the service is performed is in-network. For balance billing to be permissible, the patient must typically be given clear notice that the provider is out-of-network, an estimate of costs, and formally waive protections against balance billing through written consent.

The No Surprises Act (NSA), enacted on January 1, 2022, provides significant protections against surprise medical bills, particularly those arising from unexpected out-of-network care. This federal law bans balance billing for most emergency services, even if the facility or provider is out-of-network. It also prohibits balance billing for certain non-emergency services when provided by an out-of-network provider at an in-network hospital or ambulatory surgical center, such as services from anesthesiologists, radiologists, or assistant surgeons. In these protected scenarios, patients are only responsible for the in-network cost-sharing amounts, like copayments or deductibles, that they would have paid if the provider had been in-network.

What to Do About a Balance Bill

If you receive a bill you believe to be an improper balance bill, first review all documentation. Examine the bill for accuracy, checking service dates, provider names, and the specific services rendered. Compare this information with your Explanation of Benefits (EOB) from your insurance company, which details what your insurer covered and why.

Next, contact the provider’s billing department to clarify the charges. Explain why you believe the bill constitutes an improper balance bill, referencing your insurance plan’s network status and any applicable federal or state protections.

Simultaneously, contact your insurance company to discuss the bill and your EOB. Confirm whether the service was covered and if the provider is in-network for the specific service provided. The insurer can provide additional context regarding the payment and contracted rates.

If direct communication does not resolve the issue, formally dispute the bill with both the provider and the insurer. This involves submitting a written appeal or complaint detailing your concerns and providing all relevant documentation, such as the bill, your EOB, and any correspondence. Keep detailed records of all communications, including dates, names of individuals spoken to, and summaries of conversations.

Should the dispute remain unresolved, consider seeking external assistance. Your state’s department of insurance or consumer protection agency can provide guidance and intervene on your behalf, especially if the bill falls under protections like the No Surprises Act. These regulatory bodies are equipped to investigate potential violations and help mediate disputes between patients, providers, and insurers.