It can be upsetting to receive an unexpected bill for medical services. Before you panic, do some research. You need to understand what the bill is for and who really has the responsibility for its payment.
This is called balance billing. Balance billing occurs after your insurance company has paid everything it’s obligated to pay – but the provider wants more.
For example, if your doctor charges $100 for a service, your insurance company might pay them $70. Who is responsible for the other $30? Is it part of your required out-of-pocket costs (copays, deductibles, coinsurance)?
Balancing billing can occur if you see someone who is not in your PPO network. For example, if you go to an in-network hospital for treatment, but the radiologist who reads your X-rays is out-of-network, your insurance will only pay the in-network approved costs and will often penalize you with higher deductibles and coinsurance.
Here are 5 steps you can take if you receive a balance bill.
Step 1: Determine whether the balance bill is appropriate. If the medical provider is in-network with your insurance company, or if you have Medicare or Medicaid and your provider accepts that coverage, it's possible the balance bill was a mistake.
Step 2: Check your explanation of benefits (EOB) from your health plan to make sure the services you received were covered by the plan and, if so, that the insurance company paid their portion of the bill.
Step 3: Check your EOB and bill to ensure that the balance is not for your copay, deductible or coinsurance amount. Your EOB often lists your “member responsibility” for the services. Does this match the bill you’ve received?
If you are in doubt about what portion of the bill you should pay, contact your health plan’s customer service department.
Step 4: If it still appears that you owe a balance bill, contact your state's insurance department to see if there are any consumer protections in place if you inadvertently received care from an out-of-network provider. Some states have laws for state-regulated health insurance that forbid out-of-network balance billing when a patient had no alternative for that service. Some health plans, like Allied National plans, will not penalize you when this happens.
Step 5: Keep in mind that self-insured plans are regulated by federal law, not state law, and the rules concerning balance billing differ from company to company. For instance, members who are covered by Allied’s Funding Advantage Freedom Plans are not responsible for any balance billing from providers who might not accept the reimbursement levels of the plan. If a member should encounter a balance bill from the provider because of the discount taken and is being pressured for payment, Allied will work on members' behalf to resolve any excess amount billed.
Be aware that you may have to pay the balance bill if you used a health care provider that doesn’t have an agreement with your insurer, Medicare or Medicaid, or if you received services that aren’t covered by your health insurance policy, such as cosmetic surgery. You can ask the provider whether they are willing to reduce the bill or if they will allow you to make payments.
Founded in 1970, Allied is one of the nation's oldest and most experienced third-party administrators. Allied National is a 90 Degree Benefits Company, a subsidiary of Blue Cross Blue Shield Alabama. As the small group benefit experts, Allied works with small business employers to provide unique and affordable group health benefits.
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Allied National is a 90 Degree Benefits Company, a subsidiary of Blue Cross Blue Shield of Alabama. Founded in 1970, Allied National is one of the nation's oldest and most experienced third-party administrators. We're the small group benefit experts working to provide unique and affordable group health benefits to small business employers.