Top Class Actions’s website and social media posts use affiliate links. If you make a purchase using such links, we may receive a commission, but it will not result in any additional charges to you. Please review our Affiliate Link Disclosure for more information.
Overview of Balance Billing?
Balance billing occurs when a provider sends you an invoice for the amount between the provider’s charge and the amount allowed by your insurance.
If you have private health insurance and you see someone on your preferred provider list, you don’t expect to be surprised by an out-of-network medical bill. However, balance billing still occurs for several reasons.
If you go to an in-network doctor that has a lab conveniently located in the building–even if the doctor’s office and the lab share a waiting room–the doctor’s office and the lab could have separate contracts with insurance companies. Always ask the lab if they are an in-network provider before giving in to the convenience of the service being so close by.
ER Billing Surprises
No one ever plans a trip to the emergency room. When you need to go to a hospital, you probably choose an in-network facility if one is available. Unfortunately, when you go to the ER, you may not have any way of knowing if the doctor who sees you is covered by your insurance. You may not be balance billed by the facility, but you could still end up with a large bill from an out-of-network doctor.
Why is this? Many out-of-network providers work at in-network facilities because they have their own contracts with insurers that they choose. Many ER doctors are contracted through third-party companies, which means the ER doctors are not direct employees of the hospital. Therefore, they are not in-network providers if they are not contracted with your specific insurance company.
Hospitals often use outsourcing companies to staff positions such as anesthesiologists, pathologists, radiologists and gastroenterologists. These specialists may or may not be in-network whether or not the hospital is in-network.
Some of the staffing companies are so large that even if you ask the anesthesiologist if she accepts your insurance, she might tell you she doesn’t know because the accounting people at the staffing agency handle billing and insurance matters.
Doctors Agree Patients Shouldn’t Be Stuck with Surprise Bills
The American College of Emergency Physicians (ACEP) agrees that patients shouldn’t face surprise medical bills due to balance billing practices.
ACEP has proposed a plan to protect patients from surprise medical bills by making sure all insurers pay in-network prices for ER care and asking insurers to pay a copay to the hospital directly, ensuring the insurer is the single point of contact for the patient.
According to the research institute NORC at the University of Chicago, more than half of the country’s adults have received a surprise medical bill that they believed was going to be covered by insurance. Most of these unexpected bills were for doctor’s services (53 percent), but lab tests came in a close second, representing 51 percent of the surprise medical bills.
Balance Billing Prompts Lawsuit
At least one healthcare company, EmCare in California, has faced a lawsuit over balance billing practices. EmCare’s parent company Envision Healthcare and medical group EDS-1 Practices of California were sued in 2017 by a patient who said she was not told she was receiving out-of-network care and received a surprise medical bill of more than $4,000.
