QUESTION

What is a balance bill and how can I avoid it?

Post enrollment issues | Individual Health Insurance Employer-Sponsored Coverage
ANSWER

“Balance bills,” often referred to as surprise medical bills, can occur in two circumstances that can come as a surprise to patients: 1) when you receive emergency care either at an out-of-network facility or from an out-of-network provider, or 2) when you receive elective nonemergency care at an in-network facility but receive services during your stay from an out-of-network health care provider, such as an anesthesiologist, radiologist, hospitalist, or other physician. Since the insurer does not have a contract with the out-of-network facility or provider, it may cover only a portion – or none – of the bill. In that case, the out-of-network facility or provider may then bill you for the remaining balance of the bill. These bills can be high and are often unexpected, particularly when you have made every effort to get your care at an in-network facility. No federal law currently protects patients from receiving these surprise balance bills, but many states have enacted their own laws, which protect enrollees in certain types of health plans.

The primary step in avoiding balance bills is to ensure that you use in-network doctors and hospitals whenever possible. While it is difficult to ensure you are taken to an in-network facility in emergency situations, there are some steps you can take to protect yourself from balance bills with respect to scheduled procedures.

Before a scheduled procedure at an in-network hospital, reach out to the hospital ahead of time to ask if there is any chance you will be treated by an out-of-network provider during the procedure and request that all care be provided by in-network providers. If the hospital is unable to give you that assurance, reach out to your insurer and ask them to assure you that they will cover all services provided while you are being treated at an in-network facility. Some states require insurers to cover your care as if it is in-network if they do not have a qualified in-network provider who can deliver covered services without you needing to travel an unreasonable distance or face an unreasonable delay. Those rules may vary depending on your state’s laws or the terms of your health plan.

In cases where you are made aware ahead of time that you will have to use an out-of-network provider due to unavailability of an in-network provider, if medically safe and feasible, ask if you can reschedule your procedure for a time when an in-network provider will be available. If that is not possible, reach out to your state department of insurance to understand your rights. Be wary of signing consent forms that may waive your protections against balance billing.

To learn more about balance billing and policy proposals to protect consumers, visit https://surprisemedicalbills.chir.georgetown.edu/.

If treatment from an out-of-network provider is unavoidable, ask if the doctor or hospital is willing to accept the insurer’s payment as payment in full ahead of the procedure.

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