I just heard this term a few weeks ago. My son fell off his mountain bike when he hit a root. He has taken several spills in the past, but this one ended up with him getting several cuts on his face. Luckily he was wearing a helmet and he had no other major injuries. He drove himself to the nearest emergency room. He does have insurance through his employer. The emergency department doctor felt that his injuries required suturing by a plastic surgeon. My son was assured by the ER doctor that his insurance would cover all his costs in the emergency department.
Once the claims were submitted and processed, the insurance company was willing to pay the surgeon only a very small portion of the total bill as he was an out-of-network provider. When my son talked to the representative at the insurance company, he was told that the rest of the bill was my son’s responsibility and that he should discuss it with the surgeon’s office.
This practice is called balance or “surprise” billing.
It is becoming a more common practice and there are multiple cases of patients being on the hook for several hundreds to thousands of dollars. As patients become responsible for a higher portion of healthcare costs with co-pays and deductibles and denial of payment by insurance companies, this is a dangerous trend.
Would you go to a restaurant and order off a menu that had no prices on it and then be shocked by the final bill?
There is no other service I can think of that operates under this model. I did some reading on the web about balance billing. The best resource I found was this one:
There are excellent tips on how to avoid these surprise bills, but may not be very practical, given the emergency nature of the issue.
As of December 2018, 25 states have laws offering some balance-billing protection to their residents, and nine of them offer comprehensive protections.
It is a complicated issue with both the insurance companies and the physician representatives having major differences of opinion. At the Federal level, unfortunately, not much has been accomplished to resolve this problem.
Washington state recently passed a bill that will go into effect January 2020, which effectively takes the patient out of the middle of negotiations between the provider and the insurance company. They have the option of going to arbitration if they cannot agree on the reimbursement.
For our part, the surgeon’s billing department has submitted another claim to the insurance company. We are waiting to see what the outcome will be. If he continues to be asked to pay more than his out of pocket maximum, we plan to file a complaint with the office of the insurance commissioner in the state of Washington.
I hope you or a loved one never needs emergency medical care, but if you do please be aware of this practice. In fact, it may behoove you to take some time to find out what the laws are in your state and educate yourself about it beforehand, so you can be prepared.
It could save you thousands of dollars in the long run and most importantly, a lot of heartburn!!
(Image Credits and Copyright:Callie Richmond)