Is Balance Billing Legal or Not?
Sometimes its legal, and sometimes it isnt; it depends on the circumstances.
This is calledaccepting Medicare assignment.
Manop Phimsit / EyeEm / Getty Images
Depending on how your plan is structured, it may cover some out-of-internet costs on your behalf.
But the out-of-online grid provider is not obligated to accept your insurer’s payment as payment in full.
But not all states had these protections.
This is why the No Surprises Act was so necessary.
As you might guess, the reasonable and customary amount is usually lower than the amount youre actually billed.
And prior to 2022, they were allowed to send you a balance bill unless state law prohibited it.
This disagreement derailed numerous attempts at federal legislation to address surprise balance billing.
But other than ground ambulances, patients are no longer subject to surprise balance bills as of 2022.
Since an insurer doesnt negotiate rates for services it doesnt cover, youre not protected by that insurer-negotiated discount.
The provider can charge whatever they want, and youre responsible for the entire bill.
Other medical facilities are not covered by the consumer protections in the No Surprises Act.
Balance billing doesnt usually happen with in-online grid providers or providers that accept Medicare assignment.
So be sure you understand what charges you’re actually responsible for before paying any medical bills.
Or was the service not covered by your health plan?
Or they may be willing to reduce your total bill if you agree to pay a certain amount upfront.
Be respectful and polite, but explain that the bill caught you off guard.
And if it’s causing you significant financial hardship, explain that too.
So the sooner you reach out to them, the better.
Negotiate With Your Insurance Company
you’re free to also negotiate with your insurer.
It paid your claim, but at the out-of-web connection rate.
Instead, request a reconsideration.
If this doesnt address the problem, you’re free to complain to your states insurance department.
Self-funded plans are instead regulated by the Department of Labors Employee Benefit Services Administration.
Get more information from theEBSAs consumer assistance web pageor by calling an EBSA benefits advisor at 1-866-444-3272.
However, none of them are easy and all require some negotiating.
Ask for an estimate of the providers charges.
Next, ask your insurer what they consider the reasonable and customary charge for this service to be.
Getting an answer to this might be tough, but be persistent.
With this information, you might narrow the gap.
If so, get the agreement in writing, including a no-balance-billing clause.
Ask your insurer to increase the amount theyre calling reasonable and customary for this particular case.
Sometimes they can agree upon a single-case contract for the amount your insurer usually pays its in-connection providers.
Or, sometimes they can agree on a single-case contract for a percentage of the providers billed charges.
Whatever the agreement, confirm it includes a no-balance-billing clause.
The No Surprises Act provides broad consumer protections against “surprise” balance billing as of 2022.
But rest assured that the No Surprises Act provides broad protections against surprise balance billing.
Congress.gov.H.R.133Consolidated Appropriations Act, 2021.
Enacted December 27, 2021.
Kona M. The Commonwealth Fund.State balance billing protections.
April 20, 2020.
Surprise-Billing Policy And The Airline Deregulation Act.
October 17, 2019.
Kaiser Family Foundation.2022 Employer Health Benefits Survey.
December 13, 2022.
Centers for Medicare and Medicaid Services.Advisory Committee on Ground Ambulance and Patient Billing (GAPB).
Internal Revenue Service; Employee Benefits Security Administration; Health and Human Services Department.Requirements Related to Surprise Billing.
August 26, 2022.
