Consumer Guide to Health Care Billing
What is Balance Billing?
Balance billing occurs when doctors, hospitals, or other health care providers who are not contracted with your HMO or preferred provider benefit plan (PPO) bill you for the difference between the amount your health plan pays them and the amount the provider believes to be the adequate cost of a service.
For example, assume that you visit the emergency room at a hospital that is contracted with your health plan, but the emergency room doctor who treats you is not contracted with your health plan. The emergency room doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The hospital, which is contracted with your health plan, may bill you only for your copayments, deductibles, and coinsurance amounts under your plan. It may not bill you for the additional amount not paid by your health plan. The emergency room doctor, who is not contracted with your health plan, may bill you for the $600 that your health plan didn’t pay, as well as any copayments, deductibles, and coinsurance that you owe.
What Can You Do about Balance Billing?
Make sure your doctors and other providers are contracted with your health plan.
The most important thing you can do to prevent being balance billed is to find out in advance whether your providers, including hospitals, clinics, and other facilities, are contracted with your health plan. This is important because contracted providers may not bill you for anything over their contracted reimbursement rate for covered services, or for anything other than copayments, deductibles, and coinsurance on covered services.
This is especially significant in the case of facility-based providers who might become involved in your treatment, such as radiologists, anesthesiologists, pathologists, emergency room doctors, and neonatologists. Remember that, even if a hospital is in your health plan's network, some doctors who provide services there might not be. You might be able to prevent balance billing by asking that a contracted provider be assigned to your care. In some cases, this option might not be available to you. For example, a hospital might contract with a group of doctors who are not in your network to provide emergency room care.
Also, find out whether the services you will receive are covered under your health plan. If the services are not covered, you will have to pay all of the charges yourself.
Find out in advance how much you might be balance billed.
If you know you are going to be treated by a provider not under contract with your health plan, you might be able to find out in advance how much you will have to pay.
Texas law gives patients the right to request, in advance, estimates of charges from providers and facilities and estimated payments from health plans. Doctors and other providers and health plans have 10 days to give you the estimates, so you won't be able to get them in advance in cases of emergencies. Some providers and health plans also have cost information on their websites.
The Texas Department of Insurance’s Health Insurance Reimbursement Rates Consumer Information Guide lists average costs for common medical procedures for different regions in Texas. Websites -- such as www.guroo.com, www.fairhealthconsumer.org, and www.txpricepoint.org -- can also help you estimate the prices of various procedures. TDI’s guide and www.guroo.com list average amounts insurers pay for common medical procedures, while fairhealthconsumer.org and www.txpricepoint.org list average amounts providers charge, before any discounts.
The estimated charges that the health plan gives you should reflect what is covered under the insurance policy. The estimate should also show the cost of any deductibles, copayments, coinsurance, or other amounts that you’ll have to pay.
By comparing the provider and facility charge estimates to the health plan's estimated payments, you should be able to come up with a reasonable estimate of how much you might be balance billed.
Work out payment options in advance.
If there aren’t any contracted providers available, your health plan might be able to work out a discounted payment arrangement in advance. You might also be able to directly negotiate payment options in advance with a provider. In some circumstances, the health plan may be required to ensure that you are not balance billed.
Work out payment options afterward.
Even if you have been surprised with a bill from an uncontracted provider, you still might have options. If you think your health plan has not paid what it should have under your policy, contact your health plan to discuss the issue. If you are still not satisfied, file a complaint with the Texas Department of Insurance (TDI) at www.tdi.texas.gov/consumer/complfrm.html.
If you think a doctor or provider has overcharged you, discuss your concerns with them. Texas law requires providers to provide an itemized bill on request in most situations, so review the charges carefully. You might be able to negotiate an extended payment plan, and some providers might accept a reduced payment in exchange for immediate payment. Keep in mind that many of the bills will come separately, so you’ll need to negotiate with each provider individually.
Determine if mediation is available.
In some cases, you can require your provider and your carrier to attend mediation to try to work out the claim. If the mediation is unsuccessful, you may be able to require that they resolve the dispute with you in court.
For more information about mediation and to determine if you're eligible for mediation, visit www.tdi.texas.gov/consumer/cpmmediation.htm.
If mediation isn’t available, consider asking your provider to negotiate the charges. You can compare the amount you were charged to the average market price using TDI’s Health Insurance Reimbursement Rates Consumer Information Guide or websites such as www.guroo.com, www.fairhealthconsumer.org, and www.txpricepoint.org.
Consider whether the parties would agree to mediation.
As a way to avoid costly litigation, the parties might voluntarily consider mediating their dispute. The University of Texas Center for Public Policy Dispute Resolution has resources for people considering mediation, including links to local community dispute resolution centers. Visit https://law.utexas.edu/cppdr/.
Complain to the right agency.
If you believe you’ve been treated unfairly, file a complaint with the agency that regulates your provider or health plan.
File complaints against doctors with the Texas Medical Board at www.tmb.state.tx.us/page/place-a-complaint.
File complaints against hospitals, ambulatory surgical centers, or other facilities with the Texas Department of State Health Services at www.dshs.state.tx.us/hfp/complain.shtm.
File complaints against licensed health maintenance organizations and health insurance companies with TDI at www.tdi.texas.gov/consumer/complfrm.html.
For More Information
Texas law gives you the right to get billing information from your health plan and provides other consumer protections. Read the text of the law at www.capitol.state.tx.us/tlodocs/80R/billtext/html/SB01731F.htm. Keep in mind that the law only applies to fully insured health plans, not to government-sponsored or self-funded employer plans, also known as ERISA plans.
To get consumer information about doctors from the Texas Medical Board, visit www.tmb.state.tx.us/page/consumer. To get information about hospitals and other similar facilities and to read the Consumer Guide to Health Care published by the Texas Department of State Health Services, visit www.dshs.state.tx.us/thcic/consumerguide/consumerguide.shtm.
To get more information about health insurance coverage from TDI, visit www.tdi.texas.gov/health/index.html.
For more information contact:
Last updated: 10/22/2015