Balance Billing Does Happen!

An older couple looking at papers on a couch.

Balance Billing

Surprise! Medical Bills!—also known as balance billing — occur when you receive a bill from a hospital, health care provider, or doctor who isn’t a part of your provider’s network. These out-of-network providers have not agreed to treat members of your network for discounted fees. This leads to higher rates for you.

But Why?

Some individuals may become confused by these bills, not realizing that even under plans that cover out-of-network providers you are expected to pay the difference for what the provider charges and what your plan covers. In a couple of words this is called balance billing. Preferred providers are the only ones who cannot bill you for health care provided.
Like most things in life, there is an exception to this rule. Generally, you aren’t required to pay any balance-billed charges if you receive out-of-network care in a true emergency situation. What you pay to the provider will go towards your overall deductible, however. Should your charges exceed $500, you can request mediation. Of Course our account managers here at Primary Care Insurance Solutions are always here to help with any claims.

Network is Key

The costs individuals have to cover for out-of-network balance billing is quite startling. Unfortunately, it’s a common occurrence. One national survey revealed that 11% of privately insured individuals used out-of-network care in 2015 alone. Out of those claims, 40% were related to emergency medical care and resulted in involuntary expenses.
The best way to avoid surprise balance billing is by choosing providers that are part of your network coverage. You can use your plan’s preferred provider directory, if applicable, to find and use doctors who are a part of your network.

What You Can Do About A Balance Bill?

If you receive a surprise bill in the mail, there are several things you can do.

  • You can call the doctor or provider and discuss your concerns.
  • Check your bill thoroughly to see if any added charges are there.
  • Contact  Primary Care Insurance Solutions for assistance
  • If your bill exceeds $500 you can seek out mediation to reach a payment agreement.
  • File a complaint about your balance billing.

Balance billing doesn’t have to happen to you. By staying within your plan’s network, you can save yourself the heartache of receiving an unplayable bill.

Contact Primary Care Insurance Solutions to learn ways to avoid these charges and to help you if you encounter them.

As a healthcare consumer, you may have experienced the frustration of receiving a medical bill that’s higher than you expected. This is often due to a practice known as balanced billing, which occurs when a healthcare provider bills you for the difference between what they charged and what your insurance paid.

Balanced billing can be a confusing and controversial practice that leaves patients with unexpected and sometimes hefty bills. In this blog post, we’ll explore what balanced billing is, why it happens, and what you can do to protect yourself from it.

What is Balanced Billing?

Balanced billing occurs when a healthcare provider bills you for the difference between what they charged and what your insurance paid. This can happen when you receive care from an out-of-network provider, or when your insurance only covers a portion of the cost of a procedure.

For example, let’s say you need to have a procedure that costs $1,000. Your insurance company covers 80% of the cost, leaving you responsible for the remaining $200. If the provider you see is out-of-network, they may bill you for the full $1,000, leaving you responsible for the remaining $800.

Why Does Balanced Billing Happen?

Balanced billing is often the result of a complex system of reimbursement and payment between insurance companies and healthcare providers. Providers may charge more than what insurance companies are willing to pay, and insurance companies may only cover a portion of the cost of certain procedures.

This can lead to a situation where the provider bills the patient for the difference, which can be a significant amount of money. For patients, this can be frustrating and unexpected, especially if they were not aware of the potential for balanced billing before receiving care.

What Can You Do to Protect Yourself?

If you’re concerned about balanced billing, there are steps you can take to protect yourself. First, it’s important to understand your insurance coverage and the potential for balanced billing before seeking care.

You can do this by reviewing your insurance policy or contacting your insurance company to ask about their policies around out-of-network care and balanced billing. You can also contact your healthcare provider before receiving care to confirm whether they are in-network with your insurance company and what your expected out-of-pocket costs will be.

In addition, some states have enacted laws to limit or prohibit balanced billing. If you live in one of these states, it’s important to understand your rights and protections under the law. You can do this by reviewing your state’s regulations or contacting a consumer advocacy organization for assistance.

Finally, if you do receive a bill for balanced billing, it’s important to review the charges carefully and contact your healthcare provider and insurance company to dispute any charges that you believe are incorrect.

Balanced billing can be a frustrating and unexpected expense for healthcare consumers. By understanding your insurance coverage, seeking care from in-network providers, and advocating for yourself when necessary, you can protect yourself from the potential costs of this controversial practice.

FAQ

What is balanced billing, and why does it happen?

Balanced billing, also known as surprise medical bills, occurs when you receive a bill from a healthcare provider who is not in your insurance network. They charge you for the difference between their fees and what your insurance covers. This happens because out-of-network providers haven’t agreed to discounted fees like preferred providers.

Can you give an example of how balanced billing works?

Sure! Let’s say you need a procedure that costs $1,000. Your insurance covers 80% of it, leaving you with a $200 copayment. If the provider you see is out-of-network, they might bill you for the full $1,000, and you’d have to pay the remaining $800, which can be a real surprise.

Is balanced billing common?

Unfortunately, yes. It’s more common than we’d like it to be. A national survey showed that 11% of privately insured individuals used out-of-network care in 2015, and 40% of those claims were related to emergency medical care, leading to involuntary expenses.

How can I avoid balanced billing?

The best way to avoid balanced billing is by sticking to in-network providers. You can use your plan’s preferred provider directory to find doctors who are part of your network. That way, you won’t get caught off guard by unexpected bills.

What if I receive a surprise bill in the mail?

Don’t panic! There are steps you can take. First, call the doctor or provider to discuss your concerns. Check the bill carefully for any added charges, and if it exceeds $500, you can request mediation to reach a payment agreement.

Can I avoid paying balance-billed charges for emergency care?

In most cases, you won’t have to pay balance-billed charges for emergency care. You’ll still have to pay what your insurance doesn’t cover, but anything over $500 can be mediated. That’s where we, at Primary Care Insurance Solutions, can step in to help with any claims.

Why do out-of-network providers charge more than what insurance covers?

Out-of-network providers may charge more because they haven’t agreed to the discounted fees that in-network providers accept. This can lead to higher rates for the services they provide, leaving you with a higher bill.

Can I file a complaint about balance billing?

Absolutely! If you encounter balance billing and believe it’s unfair or incorrect, you can file a complaint. We encourage you to advocate for yourself and question any charges that don’t seem right.

Are there states that have laws against balanced billing?

Yes, some states have enacted laws to limit or prohibit balanced billing. If you live in one of these states, it’s essential to know your rights and protections under the law. Check your state’s regulations or seek assistance from a consumer advocacy organization.

How can Primary Care Insurance Solutions help with balanced billing issues?

We’re here to support you every step of the way! Our account managers are ready to assist you with any claims, questions, or concerns about balanced billing. We’ll work tirelessly to help you navigate the complexities of healthcare billing and find the best solutions for your needs.

Related Posts