Balance Billing by hospitals and other medical providers has become very problematic for insureds under health insurance policies. If you have health insurance, there are probably certain restrictions in your policy as to which hospital or medical providers you can use. If your health insurance carrier has an agreement with a hospital or medical provider, then that hospital or medical provider would be considered to be “in network”.  If your health insurance carrier does not have an agreement with a hospital or medical provider, then that hospital or medical provider would be considered to be “out of network”. In network hospitals and medical providers have an agreement with your health insurance carrier that they will only charge certain amounts for the procedures they provide. Out of network hospitals and medical providers have no agreement on how much they can charge for their services or procedures with your health insurance carrier. As such, they can charge you whatever amount they choose for the services they provide. Therefore, if you receive treatment at an out of network hospital or medical provider, they will bill your insurance company for the services. However, your health insurance carrier will only pay what it finds to be fair and reasonable for the treatment you received. Rarely will your health insurance carrier and the out of network hospital or medical provider agree on the fair and reasonable costs of the medical services provided. The out of network hospital or medical provider will then bill you for the balance of the bill not paid by your health insurance carrier.

As an example, if you received an MRI of your knee at a hospital which had an agreement with your insurance carrier that they may charge only $500. This hospital would be “in network” because they have an agreement with your insurance company. However, if you received this same MRI at a hospital which was not in your network, the hospital may charge you $3,000 for the MRI. Since you were out of network at that hospital, your insurance company may only pay $500 of your $3,000 bill for that MRI. The out of network hospital would then bill you the difference between what they charge for the MRI and what was paid by your insurance company. This would result in your receiving a bill for $2,500. This situation usually arises with emergency room visits. However, it can also arise with elective surgery or scheduled surgeries at hospitals.

Have you been treated by an out of network hospital, doctor or medical provider? Has the hospital, doctor or medical provider billed you for the difference between the amount they normally charge and the amount which was paid by your health insurer? This is not an uncommon practice by hospitals. If this is your situation, call me. I may be able to help reduce the bill being charged by the out of network hospital.