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 provides free legal support to eliminate the need for members to deal with unfair collection attempts.
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.
1/14/2021 11:29:56 am
Wow, wonderful blog layout! How long have you been blogging for? you made blogging look easy The overall look of your web site is excellent, let alone the content!
1/19/2021 01:33:45 pm
I can see how a business could really benefit from getting the right billing in order to be more effective. Making sure that they can get some help from a professional could allow them to manage their financials better. It was interesting to learn about how balance billing can differ from company to company, and make sure that they are covered by the plan.
9/23/2021 07:40:31 am
Even i too have faced similiar problem earlier. Thanks for helping me out on this.
10/3/2021 09:36:04 pm
Thanks for writing an article that I found easy to read and understand. I just found this site and am looking forward to reading more of your posts!
Thanks for helping me understand that the billing will be different for every company, since it is regulated by federal law. I guess antibiotic infusion therapy billing services would be a huge help for medical facilities to process these things. They would have the expertise to understand the need information to file the claims properly.
1/3/2023 09:28:48 pm
It's interesting to know that there can be instances wherein the bill was made by mistake because of not being updated with your insurance provider. I guess hospitals and clinics should have experts to help them with their processes such as urology billing services. It will reduce the issues that can affect their patients and their families, so they will not worry about that aspect anymore and focus on their loved one instead.
5/10/2023 03:04:29 am
This article on how to handle the unwanted surprise of balance billing is incredibly informative and useful. The author does a great job of explaining what balance billing is and why it happens, as well as offering practical tips for dealing with it. I particularly appreciated the advice on how to negotiate with providers and how to seek out legal resources if necessary. This is an issue that can be very confusing and stressful for patients, so it's great to have such clear and actionable guidance. Overall, I would highly recommend this article to anyone who wants to learn more about how to protect themselves from balance billing.
Leave a Reply.
Welcome to the Allied Blog
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.
© 2022 Allied National, LLC. All Rights Reserved.