Understanding Balance Billing Laws and Protections

Balance billing is a common issue that can arise when you receive medical care.

In the US, balance billing is prohibited under the No Surprises Act, which went into effect in 2022. This law protects patients from unexpected medical bills.

If you receive emergency care from an out-of-network provider, you won't be balance billed for the emergency services.

Balance billing, also known as surprise billing, is the difference between what your insurance provider is willing to pay and what your facility charges you for services received.

It's usually unexpected and catches patients off guard, hence the term surprise billing. This can happen when you receive care from an out-of-network provider or facility, even if you're at an in-network facility.

Out-of-network providers don't have an agreement with your insurance company to accept their payment in full, so they may bill you for the difference.

Some health plans, like PPO or POS plans, include coverage for out-of-network care, but the provider may still balance bill you if state or federal protections don't apply.

Typically, patients don't know the provider or facility is out-of-network until they receive the bill, which can be a surprise.

You may owe certain out-of-pocket costs, like a copayment or deductible, but balance billing can add even more costs to your bill.

This amount is likely more than in-network costs for the same service and might not count toward your plan's deductible or annual out-of-pocket limit.

Surprise billing can happen when you can't control who is involved in your care, like in an emergency or when you're treated by an out-of-network provider at an in-network facility.

This can cost thousands of dollars, depending on the procedure or service, and is often unexpected.

Balance billing can occur when a patient incurs an extra cost at a health facility that's not covered by their insurance deductible, co-insurance, or co-pay. This is often the case when a patient receives more services than their insurance company pays for.

Your cost of medical care can increase, leading to balance billing. This might happen if a patient requires different forms of specialized care that aren't covered by their insurance plan.

A balance bill can also result from changes in the amounts an insurer is willing to cover. For example, if a patient's insurance plan changes its coverage, you might need to send them a separate bill for the services you provided.

Out-of-network medical bills are common in scenarios where a patient requires specialized care from providers who aren't part of their network. This can lead to balance billing, as you might not be connected with the patient's insurance plan.

Balance billing is a complex issue, and it's essential to understand the laws that protect consumers.

It's illegal to balance bill in certain situations, such as when you have accepted Medicare assignments and treat a patient covered by Medicare, or when you have an agreement with Medicaid and offer services to a patient covered by Medicaid.

State regulation of balance billing is also a factor, with some states having laws to limit surprise billing. For example, Arizona, New York, Montana, California, Tennessee, and Florida have enacted laws to protect patients from balance billing.

Here are some examples of states with laws to limit balance billing:

As a healthcare provider, you have the right to balance bill a patient if you haven't agreed to the terms of their insurance, including Medicaid and Medicare. This is because you're not limited by the contract with the patient's insurer.

You can also balance bill when offering services that aren't covered by the patient's insurance package. For instance, as a dermatologist, if your patient's coverage only includes general checkups and consultations, you can legally charge them extra for a Botox treatment.

It's essential to understand that balance billing is generally considered legal in these situations, giving you the freedom to charge patients directly.

Requesting payment for services is considered illegal in certain situations. If you have an agreement with a health plan, you're not allowed to charge patients more than the plan allows.

Accepting Medicare assignments means you'll be prohibited from balance billing patients. This applies to both Medicare and Medicaid patients.

State laws also regulate balance billing, but only for health plans that are regulated by those states. Self-insured plans, on the other hand, are regulated by the federal government under the Employee Retirement Income Security Act of 1974 (ERISA).

Some states have enacted laws to limit balance billing, including:

You have certain rights and protections when it comes to balance billing. Your health plan and facilities/providers must send you a notice of your rights under the No Surprises Act.

You're protected from balance billing for emergency services, including air ambulance services, and non-emergency services at in-network facilities. Out-of-network providers can't bill you more than your in-network copays, coinsurance, or deductibles for covered services.

In emergency situations, the most an out-of-network provider can bill you is your plan's in-network cost-sharing amount. You can't be balance billed for these services unless you give written consent.

You have the right to choose a provider or facility in your plan's network. Out-of-network providers can't balance bill you unless you give written consent and give up your protections.

Here are some specific situations where balance billing is prohibited:

These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.