What is balance billing

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Last October, Aetna discouraged members from seeking emergency medical care at in-network Allegheny Health Network hospitals in Pittsburgh after out-of-network emergency physicians began 'aggressively' balance billing policy holders. In a more drastic move, UnitedHealthcare announced last year the insurer would no longer cover medical bills for members who unknowingly received out-of-network treatment by physicians at in-network hospitals.

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Balance billing is on the rise nationally. In , around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research.

In , a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

Balance billing complaints are up 1, percent in Texas. According to the Texas Department of Insurance , balance billing complaints rose from in to 1, in , an increase of 1, percent. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times.

Emergency room services to blame, in part. A Health Services Research survey found in , 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not.

For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a study from the Centers for Public Policy Priorities in Austin.

Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient.

When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance. Payers will fight out-of-network physicians with lower reimbursement rates.

Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News.

During a billing dispute with out-of-network Bayonne N. Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

Payers have sued providers for 'excessive' out-of-network fees. For more information, please visit our Resource Center. July 14, What is Balance Billing? You can usually find who's in your plan's network on your insurer's website. The cost of services rendered by in-network providers can be predictable. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.

HMOs often provide integrated care and focus on prevention and wellness. POS plans require you to get a referral from your primary care doctor to see a specialist. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost. About the National Association of Insurance Commissioners As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners NAIC provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers.