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by Antonio Arias, MBA, CHBME

Balance Billing: Why It's Coming Under Scrutiny


The “first do no harm” dictum for doctors has at least one exception: the wellness of their patients’ finances. Nowhere is that more apparent than in the least welcome surprise patients face in the U.S. healthcare system—the unexpected medical bill, typically delivered courtesy of one all-too-common practice: “balance billing.”

As many medical billing professionals know, balance billing is what happens when a physician bills the patient for the balance of a fee beyond what the patient’s insurance paid. It happens most problematically when a doctor, especially a specialist, is out-of-network for the patient. Without a contractual obligation to the payer to deliver a service at a set rate, OON physicians have free reign to charge patients as they see fit - even when the insurer only covers 50 percent or less (as they usually do).

Balance billing has been a hot-button issue for years, and it’s being a more contentious concern all the time. Why? Due to the rise of high-deductible health plans, especially those purchased on state or national healthcare exchanges, patients are increasingly budgeting for the personal financial responsibilities associated with their care and treatment. Since surprise bills can’t be budgeted for, patients and legislators alike are taking increasing note of when and why they arise.

The rise of healthcare budgeting is also placing greater attention on the laws governing balanced billing, which vary greatly from state to state. In California, for example, patients are not subject to balance billing when seeking care at out-of-network emergency rooms. Similar protections exist in 12 other states, but the specifics vary widely. (Detailed state-to-state information from the Henry J. Kaiser Family Foundation is available here.)

Insurers and patients see balance billing as a consumer protection issue, which is why Georgia legislators and others are considering imposing new regulations on the practice. Among doctors, medical associations, and healthcare groups, however, balanced billing is typically viewed as an unfortunate reality of the healthcare system… but not necessarily as a flaw.

Balance bills earn healthcare providers - especially hospitals - billions of dollars every year to their revenue cycle management. And if an insurer doesn’t cover the full costs of a service, or even a substantial percentage, who should be responsible? To providers, it’s obvious the patient is responsible for the rest. Beyond charging fair rates and helping patients pay in installments, there’s little else to be done.

But what’s important for doctors and healthcare professionals to know is that changes to the legal landscape of balance medical billing may be coming down the pike, and they could impact how much payment providers ultimately receive.

The National Association of Insurance Commissioners, for example, is developing model legislation that requires hospitals to disclose to patients if there are out-of-network providers in their system, and to give the doctors a mediation process if they’re not pleased with what the insurance company pays them. The trade group also supports a regulatory cap on what out-of-network providers can charge, pegged to the percentage Medicare pays, and they want to require doctors to bill patients nothing above their deductible if the physician files a claim against insurance.

Keeping those potential changes in mind, now may be a good time to get your financial house in order to make sure your medical billing effectiveness (balance or otherwise) is operating at its optimal level. If you’re not being paid as much from payers as you should, contact a trusted medical billing company to see how they can help you.

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by Antonio Arias, MBA, CHBME

Want to see how outsourcing medical billing can help your practice? Contact a billing expert at NCG Medical today!

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