Is Balance Billing Legal in Your State?

Balance billing, also known as surprise billing, is a practice where a healthcare provider charges a patient for the difference between their billed charges and the amount paid by their insurance company. This can happen when a patient receives care from an out-of-network provider.

In some states, balance billing is banned, while in others, it's allowed with certain restrictions. For example, in California, balance billing is prohibited, but in Texas, it's allowed unless the patient is given prior notice.

The laws surrounding balance billing vary widely from state to state, so it's essential to know the specific rules in your area. In some states, like New York, patients are protected from balance billing for emergency services.

Balance billing is a practice where a healthcare provider charges a patient for the difference between the provider's billed charges and the amount the provider is paid by a patient's insurance company. This can happen when a healthcare provider doesn't participate in a patient's insurance network.

In some cases, balance billing can be as high as 50% of the total medical bill. For example, if a patient's insurance company pays $1,000 of a $2,000 medical bill, the patient may receive a balance bill for the remaining $1,000.

Balance billing is often associated with emergency services, as patients may not have time to check if their healthcare provider is in-network before receiving treatment. However, some states have laws that prohibit balance billing in emergency situations.

Balance billing is a complex issue, and whether it's legal depends on the situation. In some cases, balance billing is allowed by law.

However, the No Surprises Act, which went into effect in 2022, prohibits surprise medical billing in emergency situations. This means that patients cannot be charged more than the in-network cost-sharing amount for out-of-network services provided during an emergency.

In other cases, balance billing is allowed, but only if the patient is given notice and has the opportunity to opt-out.

This regulation is made to provide a mechanism to resolve billing and payment disputes between insurers and out-of-network providers.

The Surprise Billing Consumer Protection Act is the law behind this regulation, aiming to establish a fair and equitable arbitration process for handling such disputes.

It applies only to "healthcare plans" and "state healthcare plans", as defined in the regulation.

Nothing in this regulation reduces a covered person's financial responsibilities concerning ground ambulance transportation.

Failure to comply with the regulation's provisions is considered an unfair trade practice.

ERISA Exempt Plans are subject to the exclusive jurisdiction of federal law and rules. This means they're not eligible for review under the "Surprise Billing Consumer Protection Act." ERISA Exempt Plans operate under a different set of rules than other plans.

Insurers are required to make available online and in print a health benefit plan surprise bill rating for hospitals. This rating is crucial in helping you understand which specialties are in-network or out-of-network.

The rating factor ranges from 0 to 4, where 0 denotes no specialties are in-network, and 4 means all specialty groups are in-network. If a hospital doesn't provide a qualified hospital-based specialty, it's designated by a green "N/A".

For ratings less than 4, the health benefit plan displays which specialty group is not in-network by marking it with a red X and including in-network specialties with a green checkmark. This clear display helps you easily understand the hospital's rating.

You're protected from balance billing in certain situations. Emergency care or treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center shouldn't result in balance billing.

Virginia state law may offer additional protection. If you receive emergency services from an out-of-network hospital or doctor at a hospital, or non-emergency surgical or ancillary services from an out-of-network lab or healthcare professional at an in-network facility, you may be shielded from balance billing.

The No Surprises Act applies to health insurance plans starting in 2022. It protects you from surprise bills for covered emergency out-of-network services, including air ambulance services.

A facility or provider can't bill you more than your in-network coinsurance, copays, or deductibles for emergency services. This is true even if the facility or provider is out-of-network.

If you receive non-emergency services from out-of-network providers at in-network facilities, you won't be billed more than your in-network copays, coinsurance, or deductibles for covered services.

You can't be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility for certain services. These services include emergency medicine, anesthesiology, pathology, radiology, or neonatology.

Some situations, like choosing an out-of-network surgeon, may allow you to agree to be treated by an out-of-network provider. However, you'd still be responsible for paying the balance bill as well as your out-of-network coinsurance, deductibles, and copays.

If you're billed an amount more than your payment responsibility, or you believe you've been wrongly billed, you can file a complaint with the State Corporation Commission's (SCC) Bureau of Insurance in Virginia.

If you have an emergency medical condition, you can't be balance billed for emergency services received from an out-of-network provider or facility. This means the most they can bill you is your plan's in-network cost-sharing amount, such as copayments, coinsurance, and deductibles.

Insurers must pay for emergency medical services without prior authorization and without retrospective payment denial for services deemed medically necessary. This means you won't be stuck with a surprise bill for emergency care.

Emergency services received from non-participating providers and/or facilities count toward the deductible and any maximum out-of-pocket policy provisions as if the services were obtained from a participating provider. This helps prevent surprise medical bills.

In cases of emergency medical services received from a non-participating facility, the facility can't bill you more than your deductible, coinsurance, copayment, or other cost-sharing as determined by your policy. This protects you from excessive charges.

Here's a breakdown of the maximum amount you can be billed for emergency services:

Insurers must also make payments to providers in accordance with prompt payment requirements. This ensures you receive timely payment for emergency services.

In some cases, you may be asked to give written consent to be balance billed for post-stabilization services. However, this is optional, and you can choose to decline.

Non-emergency medical services have specific rules to protect patients from surprise bills. In the event of a surprise bill, the insurer must pay for the services, regardless of whether the provider is in-network.

The patient's deductible, coinsurance, copayment, or other cost-sharing amount will be the maximum amount the non-participating provider can bill the patient. The provider can't bill the patient more than their policy's cost-sharing amount.

Here are the key takeaways for non-emergency medical services:

If you receive non-emergency medical services from a non-participating provider, the provider can only bill you for your deductible, coinsurance, copayment, or other cost-sharing amount as determined by your policy.

The insurer will directly pay the non-participating provider the greater of three options: the verifiable median contracted amount paid by all eligible insurers for similar services, the most recent verifiable amount agreed to by the insurer and the provider, or a higher amount as deemed appropriate by the insurer.

Non-emergency medical services received from non-participating providers count toward your deductible and any maximum out-of-pocket policy provisions as if the services were obtained from a participating provider.

Here's a breakdown of what you can expect:

In cases where you receive non-emergency medical services from a non-participating facility, the facility can only bill you for your deductible, coinsurance, copayment, or other cost-sharing amount as determined by your policy.

The insurer will make payments to providers in accordance with Code Section 33-24-59.14, and will notify the provider whether the healthcare plan is subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974.

In-network services can be a great option for non-emergency medical care. You can choose a provider or facility in your plan's network.

If you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount.

You're never required to give up your protections from balance billing. You can stick with in-network care without worrying about surprise medical bills.

Out-of-network providers at in-network facilities can't balance bill you, unless you give written consent and give up your protections. You can say no to balance billing and still get the care you need.

If you receive non-emergency medical services from a non-participating provider, the insurer will pay for the services, but you might still receive a surprise bill. This is because the non-participating provider may bill you directly for the difference between their charges and what the insurer pays.

According to Rule 120-2-106-.06, the non-participating provider should collect no more than your deductible, coinsurance, copayment, or other cost-sharing amount as determined by your policy. The insurer will directly pay the non-participating provider the greater of three amounts: the verifiable median contracted amount paid by all eligible insurers for similar services, the most recent verifiable amount agreed to by the insurer and the non-participating provider, or a higher amount deemed appropriate by the insurer.

Non-emergency medical services received from non-participating providers count toward your deductible and any maximum out-of-pocket policy provisions as if the services were obtained from a participating provider. This means that you won't be penalized for seeking care from out-of-network providers.

Here's a breakdown of what you can expect:

The insurer will pay the non-participating provider the greater of three amounts, and you won't be required to pay any additional amount beyond your cost-sharing obligations.