A "balance bill" is a charge the consumer is billed for the difference between what the insurer pays to the provider and what the provider charges for their services. If the provider is in-network, the consumer should only need to pay the expected amount for that service. The “surprise” comes when the provider is unexpectedly out of one’s network, and patients are "billed" for the remainder of the cost of services.
How a consumer may be balanced billed:
1. The consumer has an emergency medical situation.
In an emergency, the consumer may be taken to an out-of-network facility. Even if the consumer goes to an in-network hospital, there is no guarantee the providers will be in-network and charge in network rates.
2. The consumer receives care from an out-of-network provider at an in-network facility.
In non-emergency settings, the consumer will most likely select an in-network facility and provider for a procedure. The problem may come with additional services that can occur during the treatment.
ie: The surgeon may be in-network, however the anesthesiologist or surgical assistant may not, therefore a large balance bill can occur.
3. The consumer knowingly chooses to use an out-of-network provider.
A consumer may seek out a specific out-of-network provider or facility they wish to receive services from and/or complete a procedure. In this case the consumer expects they would be required to pay either the entire bill or at a higher cost depending on their plan.
Although Colorado law provides protections for consumers in the case of scenarios one and two, they are't fool proof. In Colorado, health plans are meant to hold patients harmless when treated by out-of-network providers at an in-network setting or in emergency situations, as long as the services would normally be covered. However, the law does not prohibit providers from issuing bills to consumers nor does it prevent providers from sending them to collections. Explained by 9 News consumer information clip below.
9 News - You have "No Obligation" to pay but you can still get them in the mail.
The Colorado Statute and What You Should Know
Colorado Revised Statutes Title 10 Insurance § 10-16-704
Medical Emergencies: the emergency must be qualified as a true emergency defined as -
“medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in… [serious jeopardy to the patient’s health or the health of an unborn child, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part].”
Assuming that it is a true emergency, there are some protections built in, however, they are not all-encompassing:
Balance billing is still permitted
Providers are not always affiliated with the same networks as the hospital in which they work
Deductibles and out-of-pocket maximums are excluded from the requirement that cost-sharing in emergencies be treated as in-network even if the ED is out-of-network.
Best ways to protect yourself and handle Balance Billing issues:
- Check your Explanation of Benefits. The EOBs will detail who was paid what and for what service. They will also tell you if there is the potential of a balance remaining on an out-of-network charge.
- Ask questions. For planned services always ask if the facility, doctor and all assisting in the treatment are "in network" providers. ie: physician assistant, anesthesiologist
- Check your insurance card. If you see “DOI”, “C-DOI” or a variation of the two on it, you are fully entitled to protection under the state's balance billing law.
- Complain to the Colorado Division of Insurance if you believe you've been improperly balance billed.
- Ask your insurance company to take another look at the claim
- Complain to the physician who did the actual work. In some cases, the physician might not be aware that someone working with them balance billed the patient directly. Discussing the issue directly to the doctor may also help direct your complaint directly to the out-of-network provider.
As a last resort, contact the Colorado Division of Insurance and file a complaint.
To File a Complaint with the Division of Insurance