Laura Pennington  |  June 6, 2018

Category: Consumer News

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What is Balance Billing?Balance billing is an increasingly common practice in the medical community, but one that can often confuse consumers. Certain consumers may receive higher medical bills than they anticipated despite the fact that they have insurance. These higher bills may come in the form of balance billing.

Balance billing can be an unwelcome surprise and one that sets families back significantly in terms of finances. Many people do not understand balance billing and do not realize when it has crossed the line and entitled them to possible participation in a class action lawsuit.

Patients have been increasingly facing unexpected health care bills that can have major financial effects.  Balance billing, in general, refers to a physician’s ability to bill a patient for a balance that remains after the insurance company has submitted their portion of the bill. Out-of-network doctors, who are not bound by in-network rate agreements and contracts, may be eligible to bill patients for the entire remaining balance of their bill after their insurance pays its share.

Consumers who expected that their insurance company picked up all of what the doctor would charge may receive unanticipated bills. Balance billing often happens when a patient gets a bill for care expected to be in network and covered by an insurance carrier. But if the insurance company contributes less money for a medical service than a patient expected, the doctor and practice may still be eligible to pursue the remaining amount through balance billing.

A growing number of balance billing cases have emerged in recent years. Patients often feel powerless to negotiate any costs. In 2011, approximately eight percent of individuals with private insurance used out-of-network care. A total of 40 percnet of those cases resulted in unexpected medical costs directly related to balance billing.

Another national study completed in 2015 identified that one out of every three Americans with private insurance got an unexpected bill when their insurance company paid only a portion of medical services. The rise in balance billing, according to some consumer advocates, is partially attributed to a lack of transparency with patients.

Many patients don’t even realize that they have received out of network care until the balance bill comes in the mail. Up to 70 percent of those people who received an unexpected bill did not realize that the health care provider in question was not in the plan’s network at the time of care, according to a Kaiser Family Foundation study.

Emergency room services are one common place where this occurs. These kinds of unexpected medical bills may happen when a hospital participates in the insurance company’s network, but the physicians working in the hospital do not. This can leave the patient stuck with a hefty bill for out-of-network care.

Many outsourcing firms for emergency room physicians, radiologists, pathologists, and anesthesiologists may appear in problems associated with balance billing. If you or someone you know believes you have unfairly and unexpected been targeted by balance billing, may have grounds to pursue a lawsuit. Contact an experienced attorney to learn more about your next steps.

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2 thoughts onWhat is Balance Billing?

  1. jess west says:

    People need to realize also that often times when the hospitals and insurance companies are negotiating their contracts, they can play hardball on the fee for service rate and will be in limbo. If they keep this going (I know of a case where it went into another calendar year), the patient will pick up the difference.

    Be careful out there when attempting to get medical care.

  2. Pamela Hawkins says:

    Definitely add me. I’ve received numerous times.

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