How to Fight Out-of-Network Balance Billing Surprises

A surprise balance bill from an out-of-network doctor, dentist, or hospital can devastate the finances of an unsuspecting patient.

People who need emergency treatment have the best weapon to bring to the fight: a new federal rule applies across the country and provides a game plan for patients dealing with less urgent care – beginning in 2022.

The new battle for non-urgent services centers on two competing requirements: the need for patients to understand how their health insurance works and the prerequisite for providers to disclose network participation.

Avoiding the problem in the first place is the ideal combat plan but could prove impractical while strapped to a gurney in an ambulance. Then, federal and state laws provide some cover.

How to Fight Healthcare Balance Billing

Planning is the best way to fight healthcare out-of-network balancing billing surprises. Of course, preparation is unreasonable to expect during an emergency, which is where federal and state laws come into play.

Avoiding Balance Bills

The best way to combat balance bills from out-of-network doctors and hospitals is to avoid them in the first place. As you will quickly learn, the regulations making the practice illegal pertain primarily to emergency medical treatment.

More people need treatment for chronic conditions when you have fewer legal safeguards but the opportunity to plan accordingly. Therefore, pick a participating provider, given your coverage type.  

Medicaid

Medicaid prohibits balancing billing under all circumstances for recipients: acute care and treatment of chronic conditions that allow more time to research doctors and hospitals that treat patients with this coverage.

However, patients often find it challenging to find providers that accept Medicaid because reimbursement rates are meager, and coverage for specific services varies by state.

Medicare

Medicare balance billing rules work differently, limiting but not prohibiting the practice by non-participating providers. A doctor or hospital could fall into one of three categories.

  1. Accepts assignment: charges only the approved amount
  2. Rejects assignment: bills up to 15% above the approved amount
  3. Opted out: receives no Medicare reimbursement except in emergencies

Avoid surprise medical bills 15% above the Medicare-approved amount by choosing a provider that accepts rather than rejects assignment. Verify their status before booking an appointment.

Health Insurance

The balance billing rules for private and employer-sponsored health insurance are laxer. It is legal for out-of-network doctors to charge above the allowed amount for non-emergency treatment.

Your health insurance plan should publish an online listing of participating providers with offices close to your zip code. Consult this database before setting an appointment with a doctor or hospital to avoid nasty surprises.

Federal Balance Billing Law

A brand new federal law offers the opportunity for the most significant number of patients to dispute surprise medical bills from out-of-network providers after an emergency. An interim final rule takes effect on January 1, 2022, and covers people across the country.

The nationwide interim final rule bans surprise balance billing under several circumstances:

  • Emergency services, regardless of where they are provided
  • Ancillary services (anesthesiologist) at an in-network facility
  • Other out-of-network charges without advance notice

Balance Billing Laws by State

Balance billing laws in your state can help you fight out-of-network surprises for treatment during 2021. These rules target two types of everyday situations that trap unsuspecting consumers.

  1. Valid medical emergencies
  2. Out-of-network providers working at in-network hospitals
    1. Anesthesiologist
    1. Emergency room doctors
    1. Imaging and radiology
    1. Laboratory or pathologist

California

California’s surprise medical bill law protects consumers when they go to in-network facilities such as hospitals, labs, or imaging centers or need emergency treatment. Providers cannot send patients out-of-network bills when the consumer does everything right.

Note that the law applies only to people in health plans regulated by the Department of Managed Health Care or the California Department of Insurance, which excludes three groups.

  1. Medicare
  2. Self-insured plans
  3. Medi-Cal (Medicaid)

Texas

Texas law provides certain protections against balance billing if you cannot avoid out-of-network treatment because of medical emergencies or a lack of preferred providers.

The level of legal protection varies by plan design.

  • HMO or EPO plans limit exposure to in-network cost-sharing
  • PPO plans must pay the provider based on usual, customary, and reasonable fees. Amounts above these figures paid by patients count towards the deductible and out-of-pocket maximum.

New York

The New York law protects consumers from surprise balance bills brought about by three reasons.

  1. Emergency services
  2. Out-of-network doctor at a participating hospital or ambulatory surgical center
  3. Referrals from an in-network doctor to a non-participating provider

Members of unions or self-insured plans can file disputes through the state-run Independent Dispute Resolution (IDR) Process.

Florida

The Florida law prohibits an out-of-network outfit from balance billing members of a preferred provider organization (PPO), an exclusive provider organization (EPO), or a Health Maintenance Organization (HMO). The rule applies to certain services only.

  • Emergency services without a prior authorization determination
  • Non-emergency services provided at a participating facility

Illinois

The Illinois Network Adequacy and Transparency Act (NAT) added to existing balance billing protections. Patients who act in good faith have new benefits.

  • The insurer will cover services as in-network
    • When options are inadequate
    • Emergency treatment
  • Limits on penalties for failure to pre-certify
  • Denies higher out-of-pocket costs at in-network hospitals

The Illinois law does not apply when you willfully seek out-of-network care.

How to Fight Dental Balance Billing

The strategies for fighting balance bills for out-of-network dentists are very different because the federal or state laws prohibiting the practice for emergency medical services have limits for oral care.

Even though your teeth, gums, and jaw are part of your body, the industry treats them separately, and the government does not intervene. However, every rule has exceptions.

Oral Surgery

The approach for combatting out-of-network balance billing after oral surgery is unique because health insurance acts as primary and dental insurance as secondary for many treatments.

Oral and maxillofacial surgeons specialize in surgery for the face, head, neck, and jaw, and they often participate as in-network providers with specific health and dental insurance plans.

Therefore, never pay a surprise bill from an oral surgeon before the provider submits a claim to your dental insurance as the secondary payer.

Family Dentists

The strategy for battling surprise balance bills from a dentist revolves around a deep understanding of emergency treatment rules. Your odds of a successful dispute hinge on the reason for the urgent care.

Health insurance covers emergency dental work caused by a medically necessary reason: non-biting accidents that break or damage teeth. In these cases, the laws outlined above apply when an out-of-network dentist provides care.

Dental insurance also covers emergency oral care for a broader scope of reasons. For instance, root canals fall into this category because of the intense pain. However, the same laws do not apply to mainstream dentistry and have no teeth in disputes.