Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.
How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).
Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.
There are two scenarios:
- If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
- If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.
When in doubt, check with a medical bill advocate.