The cost of medical care in the United States is astronomical, and even with health insurance, patients can still find themselves facing significant medical bills. One of the ways in which patients can find themselves facing unexpected costs is through a practice called balance billing, which occurs when a provider bills a patient for the difference between what an in-network provider charges and what the insurance company pays. In this blog post, we’ll take a closer look at balance billing with health insurance and how you can fight it.

What is Balance Billing?

Balance billing, also known as medical balance billing or surprise balance billing, occurs when an in-network health care provider bills a patient for the difference between what the provider charges and what the insurance company pays. This can happen when a patient receives care from an out-of-network provider or when a network hospital contracts with an out-of-network provider for certain services.

For example, imagine that you go to the emergency room of an in-network hospital with a severe injury. While you’re there, a doctor who is not part of your insurance plan provides treatment. After you’re released, you receive a bill from the doctor for the difference between what they charged and what your insurance company paid. This is a form of balance billing called surprise billing, and is banned by federal law as of January 2020.

How to Fight Balance Billing

Fighting balance billing can be a challenge, but there are steps you can take to protect yourself. Here are some tips to help you avoid or fight balance billing:

1. Know Your Insurance Plans: It’s essential to understand what your insurance plan covers and which providers are in-network. Review your insurance plan’s benefits and coverage information and talk to your insurance company about your network care options.
2. Check Your Bills Carefully: Always review your medical bills carefully and make sure that the services listed are covered under your insurance plan.
3. Understand State Laws: Some states have laws that protect consumers against balance billing. If you live in one of these states, it’s important to understand your rights under the law.
4. Notify Your Provider: If you receive a bill for balance bill don’t just pay it. Contact the provider’s billing department and ask them to resubmit the bill to your insurance as an in-network provider.  Never pay a balance bill from a provider who is in-network with your insurance plan, not including applicable co-pays, co-insurance, or deductibles.
5. File a Complaint: If you believe that you have been the victim of balance billing, you can file a complaint with your state’s department of insurance or the Consumer Financial Protection Bureau.
6. Take Legal Action: In some cases, taking legal action may be necessary to fight balance billing. Consider filing a case against the provider in small claims court or speak with an attorney who specializes in medical billing laws to learn more about your options.

The Bottom Line

Balance billing by in-network providers can be a significant financial burden for patients. It’s important to understand your insurance plan’s coverage and network options to avoid unexpected bills. If you do receive a balance bill, take action immediately to protect yourself and your finances.

Finally, it’s important to note that the federal government passed the No Surprises Act in 2021, which protects patients from the form of balance billing called surprise billing. This law applies to surprise billing for emergency care services and certain non-emergency services provided by out-of-network providers at in-network facilities. 

Under the law, patients are only responsible for their in-network cost-sharing amounts, and providers are prohibited from balance billing patients for any remaining amounts. It’s crucial to stay informed of changes in medical billing laws and regulations to protect your health and finances.