many hundred dollar bills and one 50 dollar bill

Balance billing. It’s a scary term, in consumer and insurance circles: That’s what happens to a consumer if the hospital or doctor (also known as the provider) and the insurance company (also known as the payer) fail to agree, even under PPO terms, and the balance that they’ve agreed upon doesn’t satisfy one or the other. So the balance is billed to the consumer.

Quite often, this is a surprise. How many times have you gone to an in-network provider, and then found that you received a bill for a little bit extra? In my case it’s been as little as 33 cents, or as much as $1,000 and change in “balance billing.”

So what should you do? Good question.

Walecia Konrad has written wisely about this in The New York Times.

“It is a controversial and sometimes illegal practice: doctors and other health care providers receive a discounted payment from the insurance company — an amount less than the fee they want to be paid — and then they bill the patient for the rest. Most states, including Illinois, have passed laws making balance billing illegal within an insurer’s medical network. And federal law prohibits balance billing by providers paid under Medicare.”

So in practical terms, what does this mean for you? if someone balance-bills then you could ask why.

Other advice: Stay in network. Double-check that the provider is in network. Know the terms of
your plan. Ask up front what the price will be. Take names, and ask all the proper associated questions: “Is this the only charge for this? Will you put that in writing?”

If you are still balance-billed, after the fact, appeal. Question. Appeal again.

In the Chicago area, a lawyer named By Adam V. Russo writes on a blog named “passionforsubro.” (Subro presumably refers to subrogation, defined by Wikipedia as “circumstances in which an insurance company tries to recoup expenses for a claim it paid out when another party should have been responsible for paying at least a portion of that claim.”)

Here’s an instructive post, about the PPO world, in which Russo and Ron Peck write about balance billing: ‘”When a patient offers their right to obtain benefits from their insurance, that assignment of benefits is in and of itself consideration in full, exchanged for services and treatment. An assignment of benefits is thus not a form of access to consideration, and rather, is the consideration itself. One might ask why a medical service provider would ever choose to accept an assignment of benefits in lieu of the right to bill a patient for 100%.”

In other words, is balance billing legal? Or fair?

If you are balance-billed, argue. Appeal. Insist.

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...