States’ Efforts to Ban Balance Billing Practices Is No ‘Surprise’

Balance Billing.

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

By Steven B. Davis and Adam J. Petitt, Stradley Ronon Stevens & Young.

Beyond a routine annual check-up and an apple a day in hopes of keeping the doctor away, individuals enrolled in private health benefit plans generally are not keen to see the inside of a hospital or emergency department. However, when emergency or more extensive treatment is necessary, so long as the patient goes to his health insurance carrier’s in-network providers, and so long as premiums, deductibles and co-insurance are paid, covered persons expect that their carrier will pay for the cost of their medically necessary care.

Unfortunately, in many states, including Pennsylvania, even if a covered individual receives treatment in an in-network hospital or emergency department (often for emergent reasons beyond their control), there is often a terrible surprise awaiting them when the bills start to arrive. In many cases after the ordeal, patients learn they were treated by an out-of-network provider when they receive an unexpected “balance bill” from that provider. This scenario is becoming more frequent in light of increasing complexity in how health care facilities contract with providers and how health insurance carriers develop their networks.

These surprise charges contribute to the rising costs of health care, and covered persons find themselves with little to no recourse. With no federal laws explicitly prohibiting this practice, a number of states are stepping up to enact “surprise balance billing” laws that protect health care consumers and ensure they receive the information necessary to make informed decisions about their health care.

August 24, 2018


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