Balance billing

Balance billing is when a provider bills you for the difference between its full charge and the amount your health plan allowed for the service. In medical billing, the “balance” is what remains of the charge after the plan pays its share and you pay your deductible, copay or coinsurance. Whether it is yours to pay depends first on one fact: did the provider have a contract with your plan on the date of service?

In network, the gap never becomes yours. The provider agreed to the plan’s rate in advance, so everything above the allowed amount is written off; on an itemized bill, look for it under payments and adjustments. Out of network there is no contract and no write-off. The plan still sets its own allowed amount and pays its share of it, but everything above that figure stays open, and the provider can bill you for it in addition to your out-of-network cost sharing.

The part people get wrong is where the network ends. Network status belongs to each biller, not to the building. You can check that the hospital is in network and still be treated by an anesthesiologist, radiologist, pathologist or assistant surgeon with a separate contract, or none. That is the classic surprise bill, and the law bars balance billing there. The reverse holds too: knowingly choosing an out-of-network doctor is not a surprise bill, and the protections do not reach that choice.

A balance bill arrives after the plan has processed the claim, often from a provider group you never chose. Put it next to the explanation of benefits for the same date and provider, which shows the charge, the allowed amount, what the plan paid and your patient responsibility. A bill asking for more than patient responsibility is asking for the balance, unless the claim was processed after the statement went out (a corrected bill is coming) or the plan denied the service (an appeal, not a balance bill).

In New York: state law bars balance billing in more cases than federal law. After emergency care, after an out-of-network clinician treated you inside a participating facility, and after a ground ambulance ride, which the federal No Surprises Act leaves out, you owe only your in-network cost sharing, and the provider and the plan settle the rest through independent dispute resolution run by the Department of Financial Services. The protection follows the plan: fully insured plans and plans bought through NY State of Health are covered, while a self-funded employer plan answers to federal law, where the ground ambulance gap is still open. Medicare has its own rule. A provider who accepts assignment takes the Medicare-approved amount as full payment, and you owe only Medicare’s cost sharing. A non-participating provider may bill more, but New York law holds it to no more than 5% above Medicare’s approved amount, except for certain home and office visits for basic examinations (procedure codes 99201–99215 and 99341–99353), where the federal limit of 15% applies instead, per the state Office for the Aging’s HIICAP Notebook. An uninsured patient has no network to be balance-billed against. For a hospital bill, the ceiling is the hospital financial assistance law: nothing out of pocket at or below 200% of the federal poverty level, no more than 10% of the Medicaid rate from 201% to 300%, and no more than 20% of the Medicaid rate from 301% to 400%. For an emergency bill they believe is excessive, they can also apply for independent dispute resolution with the Department of Financial Services themselves.

What to do:

• Do not pay it on receipt, and do not ignore it. Match it against the EOB first.
• In a protected situation, call the plan first and ask it to reprocess the claim at in-network cost sharing, then ask the provider in writing to stop billing you meanwhile.
• Read before you sign at registration. For scheduled care, a consent-to-out-of-network form can waive some protections, and you may decline it. In an emergency, a waiver generally cannot be requested at all.
• Escalate if it does not resolve: the Department of Financial Services for a state-regulated plan, and the Attorney General’s Health Care Bureau Helpline, 800-428-9071, in any case.

Also called: balance bill, surprise bill. Full guide: Surprise medical bills in New York. Reference: Balance billing on Wikipedia — general definition, not New York specifics.