Receiving a medical bill when uninsured is never fun, but at least it is expected. Receiving a bill when covered, however can be a huge surprise, especially if it is for an amount that is unaffordable. Unfortunately, this happens more often than people imagine and balance billing is the culprit.
Balance billing occurs when services are provided by an out of network provider and the provider sends the patient a bill for the balance not covered by the patient’s insurance; for example, if a patient goes to a hospital that is in their network for a problem that requires surgery, but is then operated on by a doctor that is out of network. Most insurance plans provide for care by out of network providers, but usually at much lower rates than for in network providers. Since the patient’s insurance company has no agreement in place with the surgeon, the surgeon can actually charge whatever he or she wants. Therefore, the patient is stuck with the balance between what the surgeon charged and what the insurance company will cover.
While the Affordable Care Act (ACA) was intended to curb this kind of billing practice, according to U.S. News & World Report, the ACA has actually led to an increase in balance billing. While premium costs to the consumer have gone down in many cases, insurers have removed high charging providers from their networks and the providers are then passing that financial loss on to their patients.
The Wall Street Journal reports, however, that there are some steps that consumers can take to prevent or alleviate some of these bills. While not feasible in a true emergency situation, if possible patients should research whether the doctors and hospitals they are using are in their insurer’s network. Anesthesiologists, radiologists, pathologists and specialists such as cardiologists are most likely to not accept certain health plans. Patients should always check with their insurer for information about their coverage and should never pay the provider’s bill without questioning the doctor’s office and their insurance company first.