What Is a Balance Bill? Your Rights and Protections
Navigate complex medical bills. Learn about balance billing, your patient rights, and practical steps to address unexpected healthcare costs.
Medical billing can often feel like navigating a complex maze. Understanding the various terms and processes is paramount for managing healthcare costs. Unexpected charges can appear, even after an insurance company has processed a claim, leading to confusion and financial strain. Learning about billing practices helps patients advocate for themselves and understand their financial responsibilities.
Understanding Balance Billing
Balance billing occurs when a healthcare provider charges a patient for the difference between the provider’s total charge for a service and the amount the patient’s insurance plan paid. This practice arises when a patient receives care from a healthcare provider or facility that is not part of their insurance plan’s approved network. The provider, without a contractual agreement, is not obligated to accept the insurer’s negotiated rate as full payment. They may seek the remaining balance directly from the patient.
When a provider is out-of-network, they do not have a pre-agreed price for their services with the insurance company. The provider can set their own charges, which might be significantly higher than what an in-network provider would charge for the same service. The insurance company then pays what it deems a reasonable and customary amount for the service, leaving the patient responsible for the difference.
Circumstances Leading to a Balance Bill
Balance bills frequently arise in situations where patients unknowingly receive care from an out-of-network provider. This can happen even when the primary facility, such as a hospital, is within the patient’s insurance network. For example, a patient admitted to an in-network hospital for surgery might receive services from an anesthesiologist or radiologist who is out-of-network. These ancillary providers often bill separately, and their out-of-network status can result in unexpected charges.
Emergency medical situations often lead to balance bills, as patients have no control over which medical professionals treat them or facilities they are taken to. An ambulance service, for example, might be out-of-network, even if the hospital they transport the patient to is in-network. Similarly, during an emergency room visit at an in-network hospital, the emergency physician or other specialists might be out-of-network. These situations leave patients vulnerable to receiving bills for services they could not reasonably have chosen from an in-network provider.
Patient Protections Against Balance Billing
Protections exist to shield patients from unexpected balance bills, particularly through federal legislation. The No Surprises Act (NSA) offers broad safeguards against surprise medical bills for emergency services and certain non-emergency services. This law prohibits out-of-network providers from balance billing patients for emergency care, even if the services are provided in an out-of-network facility. Patients are only responsible for their in-network cost-sharing amount, such as deductibles or copayments.
The No Surprises Act also extends protections to non-emergency services provided by out-of-network practitioners at in-network facilities. This covers situations where a patient seeks care at an in-network hospital or ambulatory surgical center but receives services from an out-of-network doctor, such as a pathologist or assistant surgeon. Air ambulance services are included under the NSA’s protections, ensuring patients are not balance billed for these often costly transports. While federal law provides a strong baseline, many states have also implemented their own protections, which can sometimes offer even broader coverage against surprise billing.
Steps to Take When You Receive a Balance Bill
Receiving a balance bill can be confusing, but several steps can help you address it. Reviewing the bill for accuracy, checking dates of service, codes for procedures, and the services rendered. Compare these details against your Explanation of Benefits (EOB) from your insurance company to identify any discrepancies. Understanding what you are being charged for is the first step in resolving any billing issue.
Contact the healthcare provider’s billing department to discuss the charges and understand their billing practices. Inquire whether they are aware of your insurance coverage and if the bill might be subject to federal protections, such as the No Surprises Act. Simultaneously, contact your insurance company to confirm what amount was paid and why there might be a remaining balance. Your insurer can clarify if the provider was out-of-network and explain the basis for their payment decision.
If the bill violates the No Surprises Act, or if you believe you were unfairly balance billed, you have the right to dispute the charge. The No Surprises Act establishes an independent dispute resolution process. You can also explore options to negotiate the bill directly with the provider, as many are willing to discuss payment plans or reduced rates, especially if the bill is substantial. Document all communications, including dates, names of individuals spoken to, and summaries of discussions, to maintain a clear record of your efforts.