Tales from the Mailbox is a blog by Health Cost Matters. In these blogs we relate stories of common billing mistakes, and five steps you can take to resolve or prevent overpaying.
In today’s blog we explore balance billing, and steps you can take to prevent mailbox surprises.
Questions regarding balance billing are among the most common we receive, and today’s Tales from the Mailbox addresses this subject.
A balance bill is when a provider bills you the difference between what he/she billed (e.g., $1,000) and what your insurance paid (e.g., $450) plus your ‘out-of-pocket’ responsibility (e.g., $50). Your balance bill in this scenario would be $500. Providers are not always allowed to balance bill you, please read on.
You Chose a Participating Surgeon, and You’re Getting Surprise Balance Bills
Susan had an endoscopy from a participating surgeon, and she was getting balance billed from the anesthesiologist. She wrote … Should she pay? Did she owe?
The anesthesiologist’s claim was $1,500, and her insurance company paid $1,350. Her bill from the anesthesiologist was for the $150 balance. Ordinarily she would have just paid this claim, but she’d heard stories about providers inappropriately balance billing patients. When this happens to you, what can you do?
First, Call the Provider’s Office to Inquire.
Before Susan contacted us, she called the anesthesiologist’s office to inquire. The billing clerk indicated that Susan’s surgeon should have informed her of her responsibility for paying the out-of-network anesthesiologist’s charges; the clerk said she’d call the surgeon’s office to ask if they’d instructed Susan about her out of pocket responsibility.
Next, she contacted us to inquire about ‘balance billing’ rules. Turns out, just her call to the anesthesiologist resolved the problem … Susan never received another word, bill or communication from that office.
Second, Were You Notified Up Front About Your Out-of-Pocket Responsibility?
Susan doesn’t recall receiving up front notification, and she did not receive a Medical Benefits Estimate of Cost or a pre-surgical amount that she would be responsible for paying. From her perspective, she’d satisfied her deductible, paid her copay and since the provider was participating there was no coinsurance or balance due. Susan chose her specialist in part because he was participating. She wondered why she was being penalized because her insurance company did not contract with the anesthesiologist.
Third, Question Surprise ‘Balance Bills’ that arrive in your Mailbox.
Inappropriate balance billing happens more often than most people realize. Red flags should go off if you receive balance bills from:
- Ancillary providers, including anesthesiologists, ER physicians, radiologists, assistant surgeons, etc., whose services are provided in conjunction with surgical, medical or hospital care. Balance billing sometimes results when your provider (physician or hospital) is participating but the ancillary provider is not.
- Non-participating providers from whom you received ER services. While you are responsible for satisfying any deductible and co-pay, depending on your plan and state statutes … you may not be responsible for total billed charges. Check your policy on this issue, it’s possible that charges (beyond copay, etc.) should be settled by your insurance carrier.
- Your participating provider. Other than deductible, copay and coinsurance, your balance due to the participating provider should almost always be $0 for ‘covered services’.
Fourth, Rules to Follow Before You Receive Services … and Before You Pay Balance Bills:
1. Always ask what you will be responsible for paying, and get it in writing. Request an Estimate of Cost prior to receiving high dollar services, especially if:
- The Estimate of Cost includes payments due to anesthesiologists and other ancillary providers. You can question those charges, request a participating alternative, or make another decision about provider if you choose … but at least you’ll be aware of your costs in advance.
- You have a high deductible that has not yet been satisfied or you have a coinsurance.
- Your surgeon or specialist is non-participating.
- Any of the services you will receive are not covered by your plan.
2. Know what you’re paying for. If no detail is included with your bill, request the detail before paying. If you don’t understand a claim, ask for clarification.
3. Was the provider participating on the date of service? If your provider was in-network on the date of service (which you can verify by contacting your health plan), the provider is paid under in-plan rules; you are responsible for deductible, copay and coinsurance.
4. Was the service denied by your insurance and if so, why? Was the service actually provided? Was it coded incorrectly? Was it denied in error? Before you pay, call your insurance company and inquire why the service was denied.
Fifth, What Else Can You Do?
This is a problem that isn't going away soon. Whether surprise balance billing is allowed or prohibited is determined state-by-state, and some states offer consumers better protection than others. According to Kaiser Family Foundation, 24 statues have laws that restrict balance billing in emergency care situations, check if your state is one. Fight back:
Check your insurance policy to determine if balance billing in an emergency is addressed.
Know if your state is one that prohibits balance billing. Contact your State Insurance Commission to inquire, or research the internet with a search such as 'Is emergency room balance billing allowed in (your state)?
Before receiving any elective surgery or treatment, obtain an estimate of cost. Specifically inquire if ancillary providers participate with your plan. These include anesthesiologist, radiologist, pathologist, and assistant surgeon.
If you discover you are on the hook for a surprise balance bill, make an appeal to your insurance company. If they are unresponsive, contact your state Department of Insurance, and inquire how to make a formal complaint. Insurance companies usually take complaints from the DOI seriously.
Contact your State Representative and your Congressional Representative. This is where legislation protecting healthcare consumers begins.
You Are Not Alone.
Overwhelmed by healthcare costs and confusing claims? Is it easier just to pay the darn bill than try to decode it and fight the system? Spiraling out-of-control healthcare costs affect us all … and billing errors occur more often than you can imagine.
Send your personal ‘tale from your mailbox’. And watch this space as we address readers’ concerns and questions.