Balance Billing: Understanding a Surprise Bill From Your Provider After a Doctor’s Visit

balance billingThere are very few individuals who can afford their healthcare entirely out of pocket. This is why a majority of people utilize health insurance which pays for most of the care. If your medical provider is an in-network provider and accepts the insurance you carry, you are guaranteed to be paying much less than if you were not covered.

But what happens when you receive a bill in the mail for services that you believed were covered by your insurance? This typically occurs when you have a motor vehicle accident and go to your family doctor using your health insurance to pay for the visit. Your health insurance company pays for most of your care, but then the doctor sends you a bill for the uncovered portion. Is that legal?

La. R.S. § 22:1874(A) prohibits any contracted health care providers from discount billing, dual billing, attempting to collect from, or collecting from an enrollee or insured a health insurance issuer liability or any amount in excess of the contracted reimbursement rate for covered health care services. This is commonly referred to as “balance billing.”

This is the attempt of a health care provider (doctor, chiropractor, physical therapist, etc.) to bill a health insurance plan at the contracted rate and then bill the patient for the difference between the contracted rate and the full rate. It occurs after you have paid your deductible, copay and your insurance company has paid everything that it is obligated to pay toward your medical bill. Unfortunately, this tactic results in thousands of patients being overbilled.

Further, La. R.S. § 22:1874(B) states that, “[n]o contracted health care provider may maintain any action at law against an enrollee or insured for a health insurance issuer liability or for payment of any amount in excess of the contracted reimbursement rate for such services.” This provision includes a lien. If a provider violates this statute, both the insurance provider and the insured have a private right of action the health care provider.

Balance billing is also not allowed if you are covered by Medicare or Medicaid. The agreement between your health care provider and Medicare, Medicaid, or your insurance company will include a clause that expressly prohibits balance billing.

However, if you are seeing a provider that does not have a contract with your insurer (out of network provider), you may end up with a surprise bill. You may also receive a bill if you are receiving services that are not covered by your insurance policy, even if you are getting them from an in-network provider. Providers should notify you of any additional charges that will not be covered before receiving treatment.

suprise medical billIf you receive a balance bill, it is first important to determine if it is legal or not. Do not just assume that you must pay the bill. If you believe your bill was an error, contact your medical provider’s billing office to get further assistance on the matter.

If it was not a mistake, you must figure out the issue and weigh your options. Did you go to an out of network provider? Or did you undergo a procedure you thought was covered? While you may not be able to avoid the bill completely, some medical offices will agree to a payment plan or possibly even reduce the bill for you. But where it is, in fact, “balance billing” the healthcare provider should forgive the balance altogether… it’s the law.


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