Physicians may refrain from participating in a health plan’s network to collect higher patient fees. Sometimes, patients may get a bill for the amount their insurance company didn’t pay because of balance billing. This happens when the provider charges more than the insurance company agrees to pay for the service.

However, this is only sometimes legal, and patients have certain protections against surprise medical bills.

What is In-Network?

In-network healthcare providers have signed contracts with your health insurance plan to provide discounted care. Your health insurance plan reimburses the provider for services up to your cost-sharing limits (copays, deductibles, and out-of-pocket maximum).

When you visit an in-network doctor, hospital, or facility, they must bill your insurance company for no more than “the reasonable and customary rate” for the service. The health insurance plan determines this through pre-negotiated agreements or state regulations.

Unfortunately, some medical treatments aren’t available in-network, and you must use out-of-network (OON) specialists or facilities to get the care you need. This can be expensive.

The good news is that the 2022 No Surprises Act prohibits balance billing in almost all scenarios except for ground ambulance transport. Your health insurance must treat out-of-network services as in-network; you’ll only be responsible for the in-network cost-sharing amounts.

However, if you receive an unexpected bill from an OON provider, contacting them and requesting they change their billing practices is still important. They may be willing to negotiate a settlement or write off the balance billing charge, mainly if it’s for a procedure not covered under your health insurance. It’s also important to review your health insurance policy and know the costs associated with out-of-network care before you seek treatment to be aware of unexpected charges.

What is Out-of-Network?

If a healthcare provider has yet to sign a contract with your health insurance plan to receive discounted payment, they are considered out-of-network. Out-of-network billing done right means that they can bill you for the total amount of the service without any restriction (in addition to any copays, coinsurance, or amounts paid towards your deductible).

Some health plans do not cover out-of-network care, while others only pay a lower “reasonable and customary” rate. Regardless of the coverage offered by your health plan, it would be best if you always tried to find in-network providers when possible.

The No Surprises Act requires that health plans reprocess claims for out-of-network services when patients notice that the provider did not perform the service or charge the agreed-upon amount. This ensures that you receive the correct benefit payment and avoids delays in reimbursement.

What is Balance Billing?

Generally speaking, healthcare providers in-network with a patient’s insurance plan must accept the rates the plan has agreed to pay for their services. However, when physicians are not in-network, they can charge whatever amount they want for their services. This is often called balance billing and can be very costly for patients who receive these surprise bills.

The goal of the new law is to help patients understand their financial responsibilities and to allow them to make informed decisions about the cost of their care. While patients can often anticipate and plan for copays, deductibles, and coinsurance, it is difficult to predict the costs associated with out-of-network service. This is why it is essential for providers to be transparent with their fees and to disclose those fees to patients before care. Physicians should also provide patients with a fee schedule upon request so that they can better understand their financial responsibilities and determine whether a visit to an out-of-network provider makes sense for them.

What are my Options?

Some states have laws that prohibit surprise billing for out-of-network services. For example, the law requires out-of-network providers to provide patients with a notice and consent form before scheduling out-of-network care. The notice and consent form informs patients about their protection from surprise medical bills, allows them to give up those protections for the particular service or facility, and estimates how much the out-of-network care will cost.

Regardless of state laws, there are still ways to get surprised by out-of-network charges. For example, some providers will bill you directly for the total amount of treatment even when they are in the network. The new federal No Surprises Act bans this practice for certain services like emergency care and ground ambulance rides.

As a practitioner, you can protect yourself from these surprise bills by being clear with your clients about what is and isn’t covered by their insurance. Understanding your client’s health plan, including who is in their network, family deductibles, and any copay or coinsurance requirements, is essential.

Also, always clearly mark boxes 13 and 27 on your insurance claim forms as ‘YES’ so the insurance company will send the payment to you. If you don’t mark them as ‘YES,’ then the insurance company will send the check to your client, and you could risk having them pocket the check for an illegal sum greater than $500/$1,000.

By Sambit