Balance Billing
From SmartMedicalConsumer Wiki
Some providers have a practice of billing a patient for all charges not paid for by the insurance plan, which is typically for those charges that are above the plan’s reasonable and customary charges or are considered medically unnecessary. This happens if the doctor or hospital is an out of network provider for the patient's insurance plan. Managed care plans (e.g., HMOs) generally prohibit in-network providers from balance billing except for allowed co-payments, coinsurance, and deductibles.
California banned the practice of balance billing for emergency care, effective on October 15, 2008. Emergency room patients can no longer be stuck with the bill when hospitals or physicians disagree with insurance companies on their fees. This means if the hospital and doctors the patient used for emergency care are not contracted providers by the patient's health plan or medical group, the doctors and hospital cannot bill the patient for more than the allowed amount (the reasonable and customary amount) by the patient's health plan.
Balance billing is a controversial practice. When patients use doctors and hospitals that are not in their insurer’s network, these hospitals and physicians may send insurers bills that are higher than what the insurance usually pays providers in their network. Insurers accuse hospitals and physicians of taking advantage of the situation and sending out inflated bills. Hospitals and physicians counter that it is the insurers that take advantage by paying far less than reasonable and customary rates. Patients wind up in the middle of such disputes when a hospital or physician bills them for the balance.
California's ban on the practice of balance billing for emergency care will save consumers money, and time and frustration spent on disputing these charges. Hospitals and physicians are protesting the rules in court. Meanwhile, the state Supreme Court is set to hear another "balance billing" challenge next month. And another court test may come sooner in a challenge by hospital chain Prime Healthcare Services Inc. of Victorville. In that case, set for hearing this month, the state Department of Managed Health Care sued Prime. The state is seeking to bar Prime from billing insured patients for unpaid medical bills that the hospital chain contends it is owed from insurers and is seeking from patients as a last resort.
Read Also
- Los Angeles Times: Hospitals protest new California rules on patient billing
- California Departmentof Managed Health Care Press Release: Regulations take effect outlawing the practice of “balance billing” for emergency care
