Website SurveyConsumer Guide to Health Care BillingBalance billing can increase your out-of-pocket costs
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What is balance billing?Balance billing occurs when physicians or other providers and hospitals or facilities who are not contracted with your HMO or preferred provider benefit plan (often referred to as a “PPO”) bill you for the difference between the amount your health plan pays them and the amount the provider or facility believes to be adequate reimbursement. For example, assume you visit the emergency room at a hospital that is contracted with your health plan, but the emergency room physician involved in your care is not contracted with your health plan. The emergency room physician and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The hospital, which is contracted with your health plan, may only bill you for your appropriate copayments, deductibles, and coinsurance amounts under your plan. It may not bill you for the additional amount not paid by your health plan. However, the emergency room physician, who is not contracted with your health plan, can bill you for the appropriate copayments, deductibles, and coinsurance amounts and for the remaining $600. What can you do about balance billing?Make sure your health care providers and facilities are contracted with your plan. This is especially significant in the case of facility-based physicians who may become involved in your treatment, such as radiologists, anesthesiologists, pathologists, emergency room physicians, and neonatologists. Remember that even if a facility is in your health plan’s network, some physicians who provide services there may not be. You may be able to prevent balance billing by asking that a contracted provider be assigned to your care. In certain circumstances, this option may not be available to you. For example, a hospital might contract with a group of doctors who are not in your network to provide emergency room care. Additionally, find out whether the services you will be receiving are covered under your health plan. If the services are not covered, you will be responsible for all charges. Find out in advance how much you might be balance billed. By comparing the provider and facility charge estimates to the health plan’s estimated payments, you may be able to come up with a reasonable estimate of how much you might be balance billed.
Work out payment options in advance. Work out payment options afterward. If you think your provider or facility has overcharged you, discuss your concerns with them. Texas law requires providers and facilities to provide an itemized statement of the bill on request in most situations, so review the charges carefully. You may also be able to negotiate an extended payment plan with a provider or facility, and some providers or facilities may accept a reduced payment in exchange for immediate payment. Keep in mind that many of the bills will come separately, and therefore you will need to negotiate with each provider. Determine if mediation is available. For more information about mediation for out-of-network hospital-based health care provider claims and to determine if you're eligible for mediation, visit www.tdi.state.tx.us/consumer/cpmmediation.htm. Consider whether the parties would agree to mediation. Complain to the correct agency. File complaints against physicians with the Texas Medical Board at www.tmb.state.tx.us/consumers/complain/placecomp.php. File complaints against facilities, such as hospitals or ambulatory surgical centers, with the Texas Department of State Health Services at www.dshs.state.tx.us/hfp/complain.shtm. File complaints against licensed health maintenance organizations and health insurance companies with the TDI at www.tdi.state.tx.us/consumer/complfrm.html. Get more information To get consumer information about physicians from the Texas Medical Board, visit www.tmb.state.tx.us/consumerbrochure.php. To get consumer information about facilities and read the Consumer Guide to Health Care published by the Texas Department of State Health Services, visit www.dshs.state.tx.us/thcic/consumerguide/consumerguide.shtm. To get more information about health insurance coverage from TDI, visit www.tdi.state.tx.us/health/index.html. For more information contact: Last updated: 09/29/2009 |