because you “always use In-Network Providers? Surprise! Not necessarily
so. Surprise Balance Billing is growing.
important health insurance issue and is causing substantial problems to
insured people and is occurring more often now that insurance
companies offer Managed Care health insurance policies almost
exclusively, and at the same time are reducing the number of
“preferred” providers in their provider networks.
Let’s say you have good health insurance, and it is a Managed Care Plan
such as an HMO or PPO, as almost all plans are today. You need to go
into the hospital for some minor surgery. You are a wise user of
healthcare so you check your plan’s network provider directory to be
sure your surgeon and the hospital are in your provider network.
come, and you wait for the insurance company to process the claim
before making any payments. The hospital and surgery discount their
bills as in-network or preferred providers so that you only owe the
remaining portion of the guaranteed amount, either a co-pay or
percentage of a smaller amount that is contracted between your plan and
the provider. As long as it is a network provider, you are only
legally obligated to pay your portion of the contracted amount. The
provider is prohibited by their contract with the insurance company for
billing you for any additional amount.
bills, this time from an Assistant Surgeon and an Anesthesiologist, two
doctors you never encountered before, at least not while conscious.
The insurance plan processes their claims and, when the Explanations of
Benefits arrive; you suddenly learn those doctors were not “preferred”
providers. They were out-of-network doctors who had no contract with
your insurance company. Those doctors bill you for a substantial amount
of money that the insurance did not cover.
requires you to use network providers, the HMO will pay $0 of those
bills. If you are in a PPO that provides some coverage for
out-of-network providers, the plan may pay a small portion of the bills.
However, without a contract with the insurance company those two
doctors can bill you their full rate and you will be legally on the
hook to pay them. By using out-of-network providers, you lost the
ability to have your portion of the bills limited.
were never given a chance to make sure those treating physicians were
part of the insurance network. I agree, it is not fair, but,
unfortunately, it is legal and is happening more frequently. You must
pay the bill in full, work out a discounted payment with each doctor, or
risk having your credit rating affected.
Actually, there is very little protection from
Balance Billing, although some states have passed legislation to
provide some relief. Prevention is the best way to avoid Balance Bills.
that helps people who must use out-of-network Emergency Rooms (ERs). It
requires insurance plans to cover charges in an ER, even if
out-of-network. In those cases, it must pay out-of-network providers no
less than what Medicare would pay for such services regardless of what
the plan normally pays out-of-network providers. Usually, the
providers will accept that payment without balance billing. However,
that does not guarantee that out-of-network providers will not still
bill you for the balance.
even though a hospital may be in-network, the doctors staffing the ER
may not be. Note that in most jurisdictions, although coverage in an
out-of-network ER is limited to “life-threatening” emergencies, courts
have interpreted that to be “life-threatening is a condition which
appears to be life-threatening by a reasonable lay person.” That means
if you have chest pains that are later determined to be bad
indigestion, it would still be considered “life-threatening” for
in a hospital or an emergency room, another possible source is when you
are referred for a consultation to a specialist. This can happen when
the health plan’s provider directory is inaccurate or outdated. It can
also occur when the referring physician makes the referral without
realizing it is to an out-of-network provider. This happens more
frequently that you would expect since most doctors belong to several
will opt to intentionally go out-of-network to see the medical provider
of his or her choice for specific reasons, realizing that they will
have to pay more out-of-pocket.
Unfortunately, there is no way to guarantee you will
never receive a Balance Bill, but there are several things you can do
to help prevent them:
- Do your homework. Before seeing any provider,
do not rely on the provider directory. Contact the provider’s
billing/insurance department, and confirm they are in the specific
network that you belong to. Note that many insurance providers use
different networks for different plans; make sure the provider is in
your specific plan’s network. Also write down the date, time,
department, and name of the person you speak with.
- If you know you will be going into a facility,
see if your doctor can give you the names of any other providers you
will be seeing, such as radiologists, pathologists, assistant surgeons,
anesthesiologists, etc. Check their network status before entering the
facility by the same methods.
- If your Managed Care Plan does not provide a
network specialist you need, or, if an out-of-network provider is a
leader in the specific area of the specific procedure you need or in
the specific condition you have, see if the Plan will agree to
authorize your visit and charge you only your in-Network portion of the
bill. This will be easier if your Network physician supports the
- If you go into an Emergency Room or are in a
hospital and an unknown physician wants to treat you, try to find out
their status with your plan. This may be difficult, as many physicians
do not personally keep track or even know to which networks they
- Check with your state’s Department of Insurance
to see if there is legislation that provides you some protection from
Balance Billing. A few states have added some protection, but the level
of protection substantially varies among the states.
- Do Not pay any bill from a medical provider
until you receive the Explanation of Benefits (EOB) from the insurance
company explaining how they processed the bill. If the EOB is slow in
coming, you may want to inform the provider’s billing office so they
will not think you are ignoring the bill.
- Call the phone number on the EOB and review
it with a Claims Representative. If it does concern an out-of-network
provider, there could be several possibilities:
a. Hopefully, the provider was
actually in-network and it was just a coding error; which will be
corrected when the bill is reprocessed.b. If it is not a coding
error, ask about your appeal rights. Appeal rights are also listed in
your plan booklet. This is especially valid if it is due to an error
that is at least partially the plan’s fault, or if it is a surprise
Balance Bill from a provider you had no option in choosing.c. Also, ask what the carrier
is willing to do to help resolve the situation. Ideally, they should
contact the provider and take you out of the middle, but admittedly,
that may not happen.
- Call the out-of-network provider and try to
arrange a reduced payment. This will be easier if the insurance company
agrees to make some payment.
Following those guidelines
should reduce your chances of getting a Balance Bill to a minimum.
Health insurance is wonderful to have, but you should not assume it
will take care of itself and always be correct in its processing.
Remember, to all the people handling your bills and insurance claims
only you have a stake in making sure it is processed accurately.