Can In-Network Providers Balance Bill?

Unexpected medical bills can cause financial stress, especially when from providers patients believed were in their insurance network. Patients often face charges they did not anticipate after receiving care they assumed was covered. Understanding patient rights regarding these billing practices is important for navigating healthcare costs and identifying improper charges.

Understanding Key Terms

Understanding medical billing requires defining “balance billing” and “in-network” providers. Balance billing occurs when a healthcare provider bills a patient for the difference between the charged amount and what the insurance plan paid or allowed. This practice usually happens with out-of-network providers, who lack a contract with their insurance company.

An in-network provider has a contractual agreement with a health insurance company. Under this agreement, the provider accepts a pre-negotiated rate as full payment for services, excluding patient cost-sharing. This provides a predictable payment structure for covered care. Patients can usually find a list of in-network providers on their insurer’s website.

Balance billing differs from common patient cost-sharing responsibilities. Deductibles, co-payments, and co-insurance are established components of a health insurance plan. A deductible is the amount a patient must pay before their health insurance begins to cover costs. Co-payments are fixed amounts for specific services, while co-insurance is a percentage of the cost of a service paid after the deductible is met. These amounts are not balance bills; they are anticipated payments outlined in the patient’s insurance policy.

Protections Against In-Network Balance Billing

In-network healthcare providers are prohibited from balance billing patients. This protection stems from contractual agreements where providers accept negotiated rates as full payment for covered services, minus patient cost-sharing. This arrangement prevents patients from being charged unexpected amounts beyond their standard co-payments, co-insurance, or deductibles.

Federal legislation, the No Surprises Act (NSA), provides protections against surprise medical bills, particularly those arising from out-of-network providers in certain situations. Enacted on January 1, 2022, the NSA addresses scenarios where patients often have little control over who provides their care. The law aims to shield individuals from unexpected charges when they receive emergency services or non-emergency care from out-of-network providers at in-network facilities.

Under the No Surprises Act, patients cannot be balance billed for emergency services, even if the facility or provider is out-of-network. The patient’s financial responsibility is limited to the amount they would pay if the services were provided by an in-network provider, including their standard co-payments, co-insurance, or deductibles. This protection extends to services received after a patient is stabilized, unless specific written consent is obtained to waive these protections.

The NSA also protects patients from balance billing for non-emergency services provided by out-of-network providers at an in-network hospital or ambulatory surgical center. This often applies to ancillary services, such as those provided by anesthesiologists, radiologists, pathologists, or laboratory services, who may not be in the patient’s insurance network despite working within an in-network facility. For these specific services, providers cannot balance bill patients or ask them to give up their protections.

While the No Surprises Act offers federal protections, some limited exceptions exist. For certain non-emergency, non-ancillary services at an in-network facility, providers may be permitted to seek written consent from a patient to waive their balance billing protections. Patients are never required to agree to waive these protections and retain the option to choose an in-network provider. Many states have also enacted their own laws that offer additional protections against balance billing, which can vary by jurisdiction.

What to Do If You Receive a Bill

Receiving a medical bill that appears incorrect or unexpected can be concerning, but several steps can be taken to address it. The first step involves carefully reviewing both the provider’s bill and the Explanation of Benefits (EOB) from your insurance company. This comparison helps identify any discrepancies, such as charges for services not received, incorrect procedure codes, or dates of service that do not align with your records. The EOB will detail what your insurance covered and what portion, if any, is considered your responsibility.

If a discrepancy is identified or the bill seems to contradict your in-network status, contact the provider’s billing department. Clearly explain your concerns, referencing the services received and your understanding of your insurance coverage or federal protections like the No Surprises Act. Request an itemized bill that lists all charges with their corresponding codes, as this can often reveal billing errors. Addressing the issue directly with them is often the quickest path to resolution.

Concurrently, contact your insurance company to discuss the bill. Your insurer can clarify how the claim was processed and confirm whether the provider adhered to their in-network agreement or the No Surprises Act regulations. If the insurance company determines the bill was processed incorrectly or that the provider violated balance billing protections, they can often intervene on your behalf. If coverage was denied, you have the right to appeal their decision.

If direct communication with the provider and insurer does not resolve the issue, you can file a formal complaint with relevant regulatory bodies. The Centers for Medicare & Medicaid Services (CMS) operates a No Surprises Help Desk, which can be reached by phone at 1-800-985-3059 or through their website. State insurance departments or consumer protection divisions can also investigate complaints related to billing practices or insurance coverage within their jurisdiction. It is always advisable to keep detailed records of all communications, including dates, names of individuals spoken to, and summaries of discussions, to support your case.