Can In-Network Providers Balance Bill?

Medical bills can be confusing, especially when an in-network provider issues an unexpected charge. This practice, known as balance billing, occurs when a healthcare provider bills a patient for the difference between the total amount charged for services and the amount the patient’s insurance company has paid. While often associated with out-of-network providers, understanding in-network agreements and legal protections is essential for patients to manage healthcare costs.

Understanding In-Network Provider Agreements

A healthcare provider is “in-network” when they have a contract with a health insurance plan. This contract sets negotiated rates for services, which the provider agrees to accept as full payment. An in-network provider accepts the insurer’s payment, plus any patient cost-sharing like deductibles, copayments, or coinsurance, as complete reimbursement. This arrangement means in-network providers cannot charge patients more than the agreed-upon rate for covered services, generally prohibiting balance billing.

Distinguishing Balance Billing from Other Costs

It is important to differentiate balance billing from other legitimate out-of-pocket expenses that patients are responsible for, even when receiving care from an in-network provider. These anticipated costs are part of the patient’s health plan design.

Deductibles represent the amount a patient must pay for covered healthcare services before their insurance plan begins to contribute. For example, if a health plan has a $1,000 deductible, the patient is responsible for the first $1,000 of covered medical expenses each year. Copayments, often called copays, are fixed dollar amounts paid by the patient for a covered service at the time of care, such as an office visit or prescription. These are typically applied after a deductible is met or independently, depending on the plan.

Coinsurance is a percentage of the cost of a covered service that the patient pays after their deductible has been satisfied. For instance, if a plan has 20% coinsurance, the patient pays 20% of the allowed amount, and the insurer pays the remaining 80%. These cost-sharing amounts are pre-determined by the patient’s benefit plan. Additionally, services not covered by insurance, such as cosmetic procedures, result in the patient being responsible for the full cost, which is not balance billing but a non-covered service.

A common source of confusion involved situations where an in-network facility utilized an out-of-network provider. For example, a patient might receive care at an in-network hospital but unknowingly be treated by an anesthesiologist, pathologist, or assistant surgeon who is out-of-network. In such scenarios, the out-of-network provider could bill the patient for the difference between their charge and what the insurance paid, leading to a “surprise bill.” These specific instances are now largely addressed by new federal legislation.

Key Protections Against Balance Billing

Federal legislation, especially the No Surprises Act (NSA), effective January 1, 2022, strengthens protections against balance billing. This law shields patients from unexpected medical bills when they receive care from providers or facilities they did not choose or know were out-of-network. The NSA applies to individuals with group health plans, individual health insurance coverage, and Federal Employee Health Benefit plans.

The No Surprises Act prohibits balance billing in several scenarios. Patients are protected from surprise bills for most emergency services, even if the hospital or providers are out-of-network. For non-emergency services, the law bans balance billing when an out-of-network provider, such as an anesthesiologist or radiologist, delivers care at an in-network hospital or ambulatory surgical center. Air ambulance services from out-of-network providers are also covered.

Specific patient consent requirements exist for out-of-network care in certain non-emergency situations. A provider must obtain a patient’s written consent to waive balance billing protections and charge out-of-network rates. This consent must be voluntary, and the patient can refuse it. For scheduled services, providers must give patients a notice and consent form at least 72 hours in advance, or 3 hours before if scheduled within that timeframe. However, balance billing protections cannot be waived for emergency services or ancillary services like anesthesiology or radiology provided at an in-network facility.

To resolve payment disputes between providers and insurers for NSA-covered services, an independent dispute resolution (IDR) process is established. This mechanism allows providers and health plans to negotiate payment amounts without involving the patient. While the federal No Surprises Act provides a broad safety net, some states have their own laws offering additional protections against balance billing.

Actions to Take When You Receive a Bill

If you receive a medical bill you believe is a balance bill from an in-network provider, a systematic approach can help resolve it.

First, review your Explanation of Benefits (EOB) from your insurance company. The EOB details what your insurance covered, amounts applied to your deductible, copay, or coinsurance, and what the provider can bill you. Compare this EOB with the bill from the healthcare provider to identify discrepancies or charges outside your expected out-of-pocket costs.

Next, contact your insurance company directly. Inquire about the bill’s specific charges and ask for clarification on coverage and payment. The insurance company can explain if the bill is a legitimate patient responsibility, like an unmet deductible, or a prohibited balance bill. They can also confirm the provider’s in-network status for the service date.

Simultaneously, contact the provider’s billing department. Explain your concerns and refer to your EOB, highlighting any charges you believe are balance billing. State that you are an insured patient who received services from an in-network provider and believe the bill violates balance billing protections. Keep detailed records of all communications, including dates, names, and conversation summaries.

Understand your rights under the No Surprises Act. If the bill is for emergency services or non-emergency services from an out-of-network provider at an in-network facility, it might be protected by the NSA. Reference these federal protections when discussing the bill with the provider or insurer.

If the issue remains unresolved after contacting both your insurer and the provider, consider filing a complaint. The Centers for Medicare & Medicaid Services (CMS) operates a No Surprises Help Desk and an online complaint process where you can report potential violations of the No Surprises Act. This formal complaint can trigger an investigation by authorities, potentially leading to an adjustment of charges. Maintain comprehensive documentation of all bills, EOBs, and communications for a successful resolution.