Surprise Medical Billing and Balance Billing
Medical bills can sometimes come as a shock, even when you believe you’re fully prepared. You carefully obtain health insurance, ensure your provider is in-network, and trust your insurance to cover necessary treatments. Yet, unexpectedly, a surprising medical bill appears, causing shock and confusion.
Surprise medical billing and balance billing are common issues in healthcare. These terms, often used interchangeably, have nuances worth exploring. Balance billing occurs when a hospital bills patients for the difference between their list prices and the amount covered by insurance. Given that hospital list prices are usually inflated, this discrepancy can significantly burden patients.
On the other hand, surprise medical billing often catches unsuspecting patients off guard. It happens when patients, despite engaging with an in-network hospital, receive care from an out-of-network provider, leading to unexpected out-of-pocket expenses. This practice is particularly prevalent as hospitals frequently subcontract departments or even individual physicians who may not be in-network.
Understanding Your Medical Bill
Understanding your medical bill is the first step in addressing this problem. Medical bills are often composed of several distinct elements. The Chargemaster Rate, or list price, represents the base price for services provided, often significantly marked up from actual costs. Then, there’s the Insurance Discount, which reflects the savings negotiated by your insurance company. The Insurance Payments indicate what your insurance company pays for your services. The remaining amount, called the Patient Balance, is what you owe.
Balance billing becomes apparent when a hospital fails to apply the insurance discount, inflating the owed amount. This is problematic as the insurance discount can account for up to 80% of the total charged amount. Surprise medical billing similarly omits the insurance discount. However, in this instance, it’s because the patient’s treatment was provided by an out-of-network provider.
Your Rights and Steps to Take
Navigating these bills can be daunting, but it’s important to know your rights. More than 24 states have regulations protecting consumers from balance billing and surprise medical billing. Laws primarily cover emergency care, though non-emergency care at in-network hospitals is less uniformly protected. At the federal level, regulations are also evolving, but progress is slow.
If you suspect you’ve been balance billed, start by researching relevant state laws. Each state has different protections, so understanding your local regulations is crucial. Contacting your insurance company can also provide clarity on whether you are being balance billed. They can assist in identifying and possibly resolving the issue.
If you reside in a state with protections against balance billing, call your hospital and explain your situation. It’s important to maintain a polite and professional demeanor to facilitate resolution. The hospital’s representative is more likely to help if treated respectfully.
In states without such protections, or if your situation falls outside the scope of existing laws, there’s still hope. Contact your insurance company and ask if they will make an exception, treating your case as if it were in-network. Be prepared for a potentially lengthy process involving multiple discussions between you, the hospital, and your insurance company.
Dealing with In-Network Billing Issues
For in-network balance billing, which occurs when a provider bills you despite a contractual agreement with the hospital, resolving the issue may be easier. Call your insurance company and verify the details of your bill using the Explanation of Benefits (EOB). Your insurance should handle the correction, but follow-up with the hospital to ensure your case is being addressed.
Conclusion
Dealing with surprise or balance billing can be incredibly stressful. It’s important to remember that you’re not alone. Many patients face similar challenges, and there are steps you can take to resolve them.
We understand how daunting and stressful these situations can be. Our website is dedicated to assisting individuals who are navigating the complexities of denied healthcare claims and unexpected medical bills. We’re here to help guide you through the process, advocating on your behalf, and ensuring your rights are protected. Contact us if you need expert assistance.
