Balance billing occurs when a provider charges a patient for the excess amount not paid by the insurance company. Also known as “surprise billing,” this type of medical bill can catch a patient off guard. While employers can take certain steps to protect employees who receive these surprise medical bills, it is important to fully understand the risk of balance billing and determine whether or not the medical bill is actually legal.
Understanding the Concept of Balance Billing
Surprise billing occurs when there is a balance owed on a medical bill after any deductibles and coinsurance have been paid and the insurance company has covered their portion of the bill. Depending on the circumstances of the situation and the insurance laws in your state, the practice of balance billing may or may not be legal.
There is a lot of confusion as to whether or not balance billing is legal. However, unless there is an agreement that the provider will not “balance bill” or if the law specifically states that balance billing is not prohibited, medical providers can and often do bill patients for any remaining amount of a medical bill that is not paid by the insurance company.
Determining Whether or Not Balance Billing Is Legal
In some scenarios, balance billing is legal. For example, an out-of-network physician that does not have a contract with a particular insurance company has the right to bill patients for any remaining balance. However, some patients may not realize that they are seeing a doctor or hospital that is out of their network. Problems also occur when a patient experiences surprised billing when they visit an in-network provider who accepts the patient’s insurance but charges more than the agreed amount.
There are certain instances in which balance billing is deemed illegal, such as when a patient has Medicare and they are using a provider that accepts Medicare assignment, when a patient has Medicaid and the healthcare provider has an agreement with Medicaid, or when a doctor or hospital has a contract with the patient’s health plan but bills for more than the contract allows..
Be Careful with Out-of-Network Providers
One of the most common reasons that balance billing occurs is when out-of-network providers work at in-network facilities. When a patient visits an in-network facility for services, they expect their providers to accept their insurance. However, this is not always the case and the patient may not realize that a certain provider does not accept their insurance until they receive a bill in the mail.
For example, a provider may send a patient to get x-rays taken but the radiologist that reads the x-rays may not be in the patient’s network. This can occur with all types of medical professionals, such as anesthesiologists, neonatologists, ER doctors, intensivists, pathologists and hospitalists.
Dealing with Unexpected Balance Billing Issues
It can be stressful for patients when they receive a medical bill that they were not expecting. There are several steps that should be taken when balanced billing occurs, starting with figuring out whether the bill is actually legal. If you believe that the bill is in error, contact the medical provider’s billing office and start asking questions. If the billing officer states that the bill was not an error, consider whether a mistake was made. If the patient accidentally visited a provider that was out-of-network, then the bill may be legal.
In some cases, you will not be able to avoid the balance bill; however, it may be possible to have the bill reduced. This may occur if you agree to pay a portion of the bill upfront, in which case the medical office may also agree to a payment plan.
Legislative Updates to Balance Billing in Virginia
In Virginia, there have been legislative updates regarding balance billing. According to these updates, when a patient receives emergency care from a provider that is out of their network or receives out-of-network ancillary or surgical services at an in-network facility, the enrollee is not legally required to pay the out-of-network provider with the exception of any applicable cost-sharing requirements. In addition, these cost-sharing requirements cannot exceed the cost-sharing requirement that would normally apply if the services were provided in-network.
Legislative updates also state that a health carrier’s mandatory payment to an out-of-network provider should be reasonable and based on services that are provided in the same geographical area. If an amount is disputed by a provider, the provider and health carrier must make a good faith effort to reach a mutually satisfying resolution.
Consulting with a Professional Benefits Consultant
Determining the best way to handle balance billing is not always easy, that is why many professionals turn to experienced benefits consultants for guidance. A benefits consultant is a knowledgeable professional that advises business clients on employee benefits, insurance, and various other products. Professional benefits consultants also provide a wide range of advice on choosing, purchasing and administering benefits.
When you contact a professional benefits consultant about balance billing issues your company may be facing, you can count on the consultant to provide you with effective advice that can aid you in your decision-making. This expertise can also come in handy when choosing benefits like insurance in the future.
Reach Out to the Experienced Benefits Consultants
Balance billing, especially out-of-network billing, has become a vital issue in modern healthcare. In fact, surprised billing is being seen across the entire United States and no patients are immune to these practices. The good news is that policymakers are making headway in preventing balance billing from occurring illegally. Both policyholders and stakeholders agree that insured customers should be protected from balance billing when they get out-of-network emergency care and unanticipated out-of-network care.
If your business is struggling with balance billing issues, it is important to speak with an experienced benefits consultant to determine what steps you should take. For more information about balance billing, reach out to a benefits consultant at Business Benefits Group.