Can a Doctor Charge More Than Your Copay? Understanding Balance Billing and Your Rights

When you visit a doctor or hospital that is in-network with your health insurance plan, you typically pay a set copayment or coinsurance amount for covered services. But sometimes patients get hit with unexpected higher bills from out-of-network providers, even at in-network facilities. This practice is known as “balance billing” and is illegal in many cases.

What is Balance Billing?

Balance billing refers to when an out-of-network doctor or hospital bills you for the difference between what your health insurance plan agreed to pay and the provider’s full billed charges.

For example:

• Your doctor’s visit fee is $200
• Your insurance plan’s in-network rate for the visit is $100
• You owe a 20% in-network coinsurance, so your expected cost is $20 (20% of $100)
• But the doctor is out-of-network and bills you for the remaining $100 balance ($200 total fee minus the $100 your insurance paid)

So even after your insurance paid, the provider balance bills you for an additional $100 that you did not anticipate paying.

When Can Balance Billing Occur?

There are a few common situations where balance billing can occur:

At the emergency room of an out-of-network hospital: You suffer a medical emergency and go to the nearest ER for treatment. Even if the hospital is not in your plan’s network, you cannot be balance billed for the ER visit itself. However, any doctors staffing the ER or if you’re admitted as an inpatient could potentially balance bill you.

When using out-of-network providers: You intentionally seek care from a doctor or hospital that is not in your network. In this case, balance billing is allowed unless prohibited by state law.

At an in-network facility using out-of-network providers: You go to an in-network facility but are unexpectedly treated by out-of-network doctors such as anesthesiologists, radiologists, pathologists, surgeons, etc. In many cases, these providers cannot balance bill you.

When referred to an out-of-network provider: Your in-network doctor makes a referral to a specialist who is out-of-network. Many surprise or inadvertent out-of-network referrals are protected from balance billing.

What Does Balance Billing Cost?

The potential cost of a balance bill depends on the procedure, but averages around $620 for anesthesia, $500 for pathology, and $754 for radiology, according to one study. Other data shows balance bills ranging from hundreds to tens of thousands of dollars in extreme cases.

Even smaller balance bills can pose a burden, especially for patients who expected to only pay their usual in-network copay or deductible. Balance billing amounts do not count towards your annual out-of-pocket limits either.

Am I Protected from Balance Billing?

In many cases, state and federal laws prohibit balance billing to protect patients from unexpected medical costs. Here are some common situations where you cannot legally be balance billed:

Emergency Services

The federal No Surprises Act protects patients from balance billing for emergency services nationwide. This includes:

• Emergency room visits
• Inpatient admission following an emergency room visit
• Stabilizing care after an emergency

You only have to pay your regular in-network cost-sharing. The most an out-of-network ER doctor or hospital can collect is your plan’s median in-network rate for the services performed.

Non-Emergency Services at In-Network Hospitals

When getting surgery or other treatment at an in-network hospital or ambulatory surgical center, you cannot be balance billed for:

• Anesthesia
• Pathology
• Radiology
• Laboratory services
• Surgeon’s assistant
• Hospitalist care

This protection applies in both emergency and scheduled visit situations. Some states also prohibit balance billing from other specialists like neonatologists and intensivists.

Out-of-Network Providers Referred by In-Network Doctors

If your in-network provider refers you to an out-of-network doctor or facility without your consent, you cannot be balance billed in most cases. This includes services like imaging and lab work sent to out-of-network labs.

When Can Providers Still Balance Bill?

There are some scenarios where health care providers can still balance bill patients who intentionally receive out-of-network care:

• Seeking non-emergency treatment from an out-of-network doctor, hospital, or clinic
• Signing a written notice that your provider is out-of-network and agreeing to balance billing

However, be aware that consenting to balance billing in writing does not always waive your protections. Certain types of common out-of-network services (like anesthesia at an in-network hospital) cannot balance bill even with consent.

Surprise or inadvertent bills also cannot be balanced billed even if you sign after the fact. Never feel pressured to sign any forms agreeing to pay extra costs.

What to Do If You Get a Balance Bill

If you receive a balance bill for emergency care, care at an in-network facility, or an unintentional out-of-network referral, take the following steps:

• Verify that the provider is actually out-of-network. Request they prove you consented to out-of-network care if needed.
• Check that your insurer processed the claim properly according to your benefits.
• Pay only the in-network cost-sharing amount you are responsible for. The provider must bill your insurer directly for the remainder.
• Keep records of all bills and communications.
• Consult with your state insurance department about your rights.
• Hire an attorney if you are unable to resolve the issue on your own.

Avoiding Balance Billing

As a patient, it is difficult to completely avoid balance billing. But here are some tips to reduce the chances of getting a surprise bill:

• Use in-network facilities and doctors whenever possible. Check they are in-network with your specific health plan, not just contracted with the hospital overall.

• Ask lots of questions about the specifics of your care upfront. Inquire about which providers will be involved and whether they are in-network.

• Refuse out-of-network care when possible. Deny any requests to sign a written consent form from out-of-network providers.

• Discuss referral options only to in-network specialists with your primary care provider.

• Review bills carefully and dispute any improper charges quickly. Identify inadvertent out-of-network claims that should be covered at the in-network level.

• Consider switching to health insurance plans with broader networks that have signed contracts with more area providers.

State Balance Billing Protection Laws

• Many states have laws providing more extensive protection from balance billing than federal laws. Some prohibit balance billing for a wider range of provider types or in certain facilities like free-standing ERs.

• Overall, states with the strongest balance billing protections include California, Colorado, Florida, Georgia, Illinois, Maine, Maryland, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, and Washington.

• However, state law cannot preempt federal balance billing prohibitions. The No Surprises Act establishes nationwide minimum standards, which apply everywhere regardless of varying state laws.

The Future of Balance Billing

Patient protection from balance billing recently expanded under the federal No Surprises Act passed at the end of 2020. This important law fills gaps that existed at the state level to protect patients nationwide.

However, efforts to further restrict or ban balance billing for all services continue at both the state and federal level. There are still scenarios where out-of-network providers can legally balance bill certain patients depending on the state, procedure, or site of service.

Patients should stay informed about new legislative developments impacting balance billing practices and how to fight back against illegal charges.

Key Takeaways About Balance Billing

• Balance billing is when you are billed for the difference between a provider’s charges and the insurer’s payment on out-of-network claims.

• Federal and state laws protect patients from surprise balance bills for emergency care and at in-network facilities.

• Review your rights and notify your insurer immediately about any improper balance bills.

• Balance billing costs patients hundreds to thousands of dollars on average when protections do not exist.

• Work proactively with your doctors to avoid inadvertent out-of-network care and resulting balance bills.