Dealing with medical bills can be confusing, especially when seeing out-of-network doctors. You may wonder – can my doctor charge me more than my insurance allows? The short answer is sometimes. There are important protections in place to limit surprise medical bills and balance billing in certain situations. However, out-of-network providers may still charge you additional fees in other circumstances.
This comprehensive guide examines when doctors can and cannot charge more than your insurance coverage, key protections against surprise bills, and what to do if you receive a balance bill from a provider.
Balancing Billing by Out-of-Network Doctors
First, it’s important to understand the difference between in-network and out-of-network doctors.
In-Network vs. Out-of-Network
In-network – Doctors and facilities contracted with your insurance company and agree to preset rates.
Out-of-network – Providers who do not have a contract with your insurer. They can set their own rates.
Out-of-network doctors have not agreed to the negotiated rates set by your health plan. This allows them to “balance bill” patients – charging you the difference between their billed charges and what your insurance paid.
For example, if your out-of-network surgeon’s fee is $5,000 but your insurance only covers $3,000, the surgeon can bill you the remaining $2,000 balance. This is called balance billing.
Key Protections Against Surprise Balance Bills
However, there are laws that protect patients from balance billing in certain situations:
You cannot be balance billed for out-of-network emergency services, including any inpatient care that follows. You only pay your regular in-network cost-sharing.
Care at In-Network Facilities
You cannot be balance billed when receiving care from an out-of-network provider at an in-network hospital, outpatient surgery center, etc. This includes services like anesthesia, radiology, or lab work.
Referrals to Out-of-Network Providers
You cannot be balance billed when an in-network doctor refers you to an out-of-network provider without your consent.
These protections apply to both insured patients and people paying cash. They prevent providers from unexpectedly balance billing you.
When Balance Billing Is Allowed
While key protections exist, there are scenarios where an out-of-network doctor may still balance bill you:
Elective out-of-network care: You select an out-of-network doctor when in-network options are available. This includes out-of-network specialists.
Certain facilities: Such as independent labs, urgent care clinics, and diagnostic imaging centers. Surprise billing protections do not apply.
No written consent: You received written notice and provided consent to see an out-of-network doctor but are still balance billed.
Insufficient notice: The provider failed to provide proper notice about your out-of-network care. But you still consented.
Self-funded plans: Federal protections may not apply to self-funded employer health plans, depending on state laws.
No provider choice: You were not given a chance to select an in-network provider in advance.
In these situations, providers may still send you a balance bill for additional costs beyond your normal cost-sharing and insurance payment.
What to Do If You Receive a Balance Bill
If an out-of-network provider bills you for more than your regular cost-sharing amount, here are important steps to take:
Review the bill – Make sure it is not a mistake by verifying the dates, services, and amount charged.
Check your EOB – Review your Explanation of Benefits from your insurer to confirm what they already paid.
Call your insurance – Contact them to explain the situation and confirm if you’re protected from balance billing.
Negotiate with the provider – Ask if they’ll reduce or waive the balance bill given your insurance’s payment.
Submit appeals – You can appeal the provider bill through your state’s dispute resolution process.
Report complaints – File complaints with your state’s insurance department if the provider violates billing protections.
Getting proactive quickly and notifying your insurer can help resolve improper balance billing situations. Be sure to keep records of all bills, EOBs, and letters as evidence.
Options to Avoid Out-of-Network Charges
While you cannot totally control whether a provider or facility is in your network, there are steps you can take to avoid surprise bills:
Check your plan’s provider directory – Avoid out-of-network doctors and confirm facilities are in-network before services.
Ask about other providers – Request in-network options when being referred for tests or procedures.
Ask billing/coding questions – Get written confirmation from providers if you will be balance billed for services ahead of time.
Negotiate payment plans – If hit with a large balance bill, work with the provider to pay it off in installments if immediate payment is not possible.
Appeal insufficient notice – File a complaint or appeal if an out-of-network provider failed to properly notify you in advance.
Staying proactive, being an informed health care consumer, and scrutinizing unexpected bills can help reduce your out-of-pocket costs.
Can doctors charge you more than your insurance allows? Sometimes – doctors may balance bill you out-of-network fees not covered by your health plan. But key protections prevent surprise balance billing in cases like emergency care or when you unknowingly see an out-of-network provider at an in-network facility. Being aware of your rights, carefully reviewing medical bills, and appealing unfair charges can help minimize the financial impacts. Discuss any questions or concerns with your health plan’s member services team to ensure you understand when you are protected from balance billing versus when you may need to pay additional out-of-network costs.
Frequently Asked Questions
Below are answers to some common questions about doctors charging more than insurance allows:
Can I be balance billed for emergency room care?
No, you cannot be balance billed for out-of-network emergency services thanks to state and federal law. This includes care received in the ER or any inpatient care after being admitted from the ER.
What if I’m referred to an out-of-network doctor without my consent?
In most cases, you cannot be balance billed if an in-network provider refers you to an out-of-network provider without your written consent. This includes things like labs, radiology, anesthesia, etc.
Are hospitals allowed to balance bill me?
No, hospitals are prohibited from balance billing in emergency situations or when you unintentionally receive out-of-network care at an in-network hospital.
Can a specialist I chose balance bill me if they are out-of-network?
Yes, out-of-network specialists you voluntarily choose, when in-network options are available, can legally send you a balance bill. The surprise billing protections do not apply.
What if I receive care outside my state?
Balance billing protections vary by state. Some states don’t allow it while others have limitations. Check the laws in the state where you received care.
What should I do if I’m balance billed?
First, call your insurance to confirm the balance bill is not prohibited based on protections in your plan or state law. If it is permitted, try negotiating with the provider to reduce or waive the charges. Your last resort is filing a complaint or appeal.
How can I prevent unexpected balance bills?
Avoiding out-of-network care when possible, asking doctors their network status, getting cost estimates in writing, and contacting your insurer if balanced billed can help protect against extra charges.
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