Balance billing is when a healthcare provider charges you a bill even after your insurance has paid them. Balance billing often happens when the physician or health care company is out-of-network. That is, the insurance company did not have a price contract with that specific health care provider or company. Nobody wins in this situation, as the health care provider usually charges extravagant list prices, the insurance company low-balls the amount they want to pay, and you’re stuck in the middle.
The way to reduce this scenario is to understand which specialties routinely balance bill, and to proactively ask if they are in-network to your insurance company before you perform the procedure.
- Anesthesiologist: make sure you ask your surgeon about the anesthesiologists that will take care of you, and that all are in-network to your health insurance company. Make sure that there are no hidden or surprise anesthesia fees for the procedure you are undergoing.
- Radiology: Ask the hospital if the radiology department and radiologists are contracted to a physician staffing company, and if they are in-network to your insurance company
- Pathology: Ask your lab if the pathologist is out-of-network, and if they will be sending your sample to another out-of-network laboratory
- Lab: ask your provider if they are sending your lab samples to an in-network facility for processing.
If any of the providers are out of network, it still may be difficult to change providers, because the company or the external providers are associated with your current primary doctor or specialist. That means, for example, the hospital only uses one firm for all of their radiology staffing, or only sends samples to one particular laboratory. To help solve this, call up the out-of-network company and try to negotiate a fee, or ask them to accept the usual and customary rate (UCR), that insurances usually pay out-of-network providers. This may be difficult in many situation, but in others, it may be easy to understand the total cost of the procedure.
The last and most common way to get balance billed is at the emergency room. Many states have since passed laws protecting emergency room patients from being balance billed. Understand your state’s laws against balance billing. You can begin here.
