Balance Billing: A Dilemma for all

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June 12th, 2012

Balance BillingBalance billing is a practice by which medical providers and facilities make the patient responsible for the amount not paid by their insurance company.  The medical facility charges a price for a service, the insurance company corrects the amount to be paid to what they agreed in their contract and pays it, then the unsatisfied medical facility bills the remainder directly to the consumer/patient.

How patients end up paying when they shouldn’t

Medical facilities justify ‘double dipping’ of payment by saying that these are the actual costs of service for which they need to collect, while the consumer fears having bad credit and just pays the additional amount even when they aren’t responsible for the charges.  Some physicians, hospitals, and labs exploit consumer confusion so the best defense is information: Know your coverage, know your policy, and if you don’t know, ask your insurance company.

balance billing

  1. The medical bill goes to the insurance company to be paid. It covers all costs for care.
  2. The insurance company only pays what they feel is:
    • Applicable to the patient's condition (appropriate charges)
    • At the contracted price
    • Services that are in network (covered)
  3. The medical facility then passes on the unpaid amounts, whether justified charges, or not, to the consumer to cover the difference.
  4. The consumer, most times out of confusion, pays the remainder, even portions of the bill not appropriate.

What does the law say?

Federal law prohibits this practice for Medicare patients and the Supreme Court ruled that balance billing for out of network emergency care is prohibited. The AMA however is lobbying fervently so that there is no ban on balance billing and instead suggests the Healthcare Balance Billing Disclosure Model Act, which promotes transparency of out-of-network health care costs. This model bill that requires health insurers, health care facilities and facility-based physicians to disclose to patients that they may receive a bill for medical services that are not paid for by their health insurance companies.

PayerFusion - We Guarantee Zero Balance Billing

At PayerFusion a paid claim is a closed claim.  Our methodology and claims management services eliminate any possibility of balance billing- guaranteed.  Our clients are our partners; together we fuse the gap between providers who deserve fair compensation and payers who seek fair prices for services rendered. We also utilize our own provider network, PayFuseNet.  It is not a PPO.  We guarantee zero balance billing to our clients as part of our comprehensive medical claim administration services, guaranteeing that patients will never be hassled by a provider for additional funds.  For more information on our medical claims management services visit our services.