How many of you have heard of balanced billing? How many of you understand balanced billing? Do not worry, most people have neither heard nor understand what balanced billing is. Medical billing has different moving parts based on Medicare, Medicaid, the type of primary insurance you have and if you have supplemental insurance. Once you move past patient registration, insurance eligibility and verification, there is the claim submission and payment posting that occurs. Payment posting is what will affect your out-of-pocket costs, if any. 

What is balanced billing? Balanced billing, sometimes referred to as “Surprise billing” is when you receive an unexpected bill for services rendered after your insurance has paid the bill. A balanced bill can occur, for example, from an emergency room visit for services provided, outside of your control, by a doctor that is out-of-network. This can also happen as a result of seeing a specialist who is not part of your network of providers.    

On the back end of insurance, there is the contractual agreement between the provider and the doctor and the provider and the hospital. This differs from the Medicare rule of 80/20 which is Medicare paying 80% of the medical bill and you are responsible for the remaining 20%.  If you have Medicare, you will receive a quarterly statement listing the services that you received, what they paid, and what you must pay. Unlike Medicare, managed care health does not have an 80/20 rule, and the difference of whatever your insurance does not pay for, you become the responsible party for that difference. Medicaid recipients should not receive a bill.

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Take note, when you sign the billing waiver at the doctor’s office, you are not only agreeing to the services being rendered but also any billing associated with the visit and payments due beyond what your insurance company does not pay. You should always scrutinize the bills you are receiving. If you have an upcoming procedure, you should make an inquiry as to whether all participants are in or out-of-network so that you do not receive any surprise bills. 

Sometimes balanced billing can be an honest administrative error or a coverage issue wherein Medicaid doesn’t provide coverage for certain procedures that you were unaware of. Oftentimes, a doctor that you have been seeing for a long time no longer accepts your insurance, does not inform you and you receive a bill for the full amount due. It could also be due to unethical practices in an attempt to get more money from the patient. 

Protect yourself and be proactive:

3 Whenever you change insurance companies, update your doctor’s office with the new information. This will avoid any unnecessary billing, delays in processing or scheduling upcoming appointments and procedures.

3 Make sure your basic information is correct, to include your plan ID and dates of service.

3 Do not be afraid to look at your bill. As soon as you receive it, do not toss it into a” read later pile.” You will want to address any discrepancies right away.

3  Protect your credit and communicate with your provider’s billing department right away. Let them know that you are working on it. Medical bills that have been in collection for a year will be reported to the credit bureaus. However, if you’ve paid off your medical, effective July 2022, TransUnion, Equifax, and Experian will remove the negative credit reporting.

3  Inform your plan, whenever possible and in a non-emergency case, of any upcoming procedures to ensure that the hospital, doctors, and specialists are a part of your network services; sometimes referrals are not needed, therefore you want to make sure you cover your basis.

3  Know what your insurance does and does not cover.

The Balanced Billing Protection Act protects patients from being railroaded into paying for services that are contractually covered whether it is an emergency service at a hospital that is in-network or at a treatment center and seen by an out-of-network provider. As of January 1, 2020, this applies to all state-regulated health plans. The Affordable Care Act also requires most private insurance companies and Medicare to cover many preventative services to include screenings for a colonoscopy, blood pressure, and adults who are at risk of a chronic disease, for example, ESRD (End-Stage Renal Disease).*

*Note:  Insurance plans that are grandfathered (in existence prior to March 23, 2010) and have not made significant changes to coverage since then, are not required to cover preventative tests completely.

Balanced billing is deemed illegal for those who have providers that accept Medicaid or Medicare. If your providers have a contract with your health plan and they send you a bill to cover the difference of what the contract allows, that’s balanced billing and it is illegal. If you feel that you that are in receipt of a balance bill, you should contact the provider first, in writing. If you do not get any resolve there, then contact Centers for Medicare and Medicaid Services on their website

If you have questions or would like to read about a specific healthcare topic, please email your questions to I look forward to your engagement.

La-Villa Brooks
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