Balance billing

Last updated March 25, 2024

Balance billing, sometimes called surprise billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays.^[1] It is a pervasive problem in the United States with providers who are out of network, and therefore not subject to the rates or terms of providers who are in-network. Balance billing has a variable prevalence by market and specialty.

Advocates of balance billing argue that it increases the incomes of high-quality healthcare providers and measures their dissatisfaction with insurance company fees.^[2] Critics say that balance billing lets providers raise charges through stealth rather than transparent pricing, creates unnecessary administrative costs and patient confusion, and allows providers to simply pass along costs to patients, rather than helping them to secure good value.^[3] It is thought to erode political consensus in favor of a one-tier system of healthcare, and to inhibit some people from getting the care they need, by making that care more expensive.^[4]

Canada

Throughout the 1970s in Canada, the country saw an increase in balance billing, which in Canada is normally called extra billing. It was not permitted in Quebec or British Columbia, but had been encouraged in Ontario and Alberta, and tolerated in other provinces. The federal government estimated that by 1983, extra billing across Canada totaled $100 million. The government believed that extra billing enabled the creation of a two-tiered Canadian healthcare system, in which people who could not afford extra charges would receive lesser care.

In 1984, the government passed the Canada Health Act, which promised universal and comprehensive health coverage for all Canadians, and which contained provisions to discourage user fees and extra billing by imposing financial penalties on and reducing transfer payments to provinces that permitted them.^[5]^[6]^[3] In 2002, five provinces prohibit all extra-billing, while Alberta, British Columbia (BC), and Newfoundland allow it in a small number of circumstances, and Prince Edward Island and New Brunswick do not restrict it at all.^[7]

In 2003, the BC government enacted the Medicare Protection Amendment Act, which banned extra billing for medical services and diagnostic procedures deemed medically necessary and covered by the provincial Medicare system; however, many of the provisions were not enforced. In 2018, the government announced its intention to implement operational requirements more stringently and to impose financial penalties for extra billing for medically necessary diagnostic procedures. However, enforcement of medical procedures was delayed until after March 31, 2020, and diagnostic procedures until April 1, 2020, because of a court injunction in the case that would ultimately become Cambie Surgeries Corporation v. British Columbia.^[8] On September 10, 2020, the Supreme Court of British Columbia dismissed the Cambrie plaintiffs' claims.^[9] The plaintiffs filed a notice of appeal and in July 2022, the BC Court of Appeal upheld Justice Steeves' decision.^[10]^[11]

United States

Health insurance in the United States is typically provided by a managed care plan with a preferred or exclusive "network" of providers; balance billing does not occur with providers in-network, as the insurer negotiates an agreed rate ahead of the service.^[12] However, out-of-network medical billing has become common for privately insured patients even when they receive care in an in-network hospital, creating a substantial financial burden.^[13] Surprise balance billing is when an out-of-network provider bills an individual for services that were not covered by the insurance plan. This is often a surprise because an individual may be unaware that the services were out-of-network or did not actively choose to receive in an inpatient setting.^[14] The "growing risk to patients of incurring burdensome unexpected out-of-network bills" has received significant attention in the 21st century.^[13]

Out-of-network care in the United States is very common and unavoidable in emergencies.^[15]^[16] A 2017 study published in Health Affairs concluded that in 2014, one in five inpatient emergency department causes will lead to surprise bills, and that 20% of emergency department admissions, 14% of outpatient visits to the emergency department, and 9% of elective inpatient admissions likely incurred a surprise medical bill.^[15] A 2020 Peterson-KFF Health System Tracker found that, "for people in large employer plans, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge associated with the care in 2017."^[16] However, surprise billing also occurs in planned-care (non-emergency) settings: for example, when a patient receives care at an in-network hospital or ambulatory surgery center, only to subsequently learn that a specific provider or providers providing the treatment (such as an anesthesiologist or radiologist) does not participate in the network of the patient's health plan.^[16] In both circumstances, "the patient is not in a position to choose the provider or to determine that provider's insurance network status."^[16]

A 2019 Commonwealth Fund report identified 28 U.S. states as having at least some consumer protections relating to balance billing."^[17] This was an increase from 2017–2018, when a total of 25 states had at least some protections against surprise billing.^[14] Of the states with consumer protections relating to balance billing, only nine states have comprehensive protections at the end of 2018.^[17] That number rose to 13 states in 2019.^[17] Researchers consider a state to offer "comprehensive protections" against surprise bills if the state's law limits a consumer's "financial exposure to normal in-network cost sharing"; bars providers from balance billing; applies to both emergency department and non-emergency care in an in-network hospital; applies to both HMO and PPO enrollees; and creates a method for resolving payment disputes between providers and insurers (either through a specific payment standard or a dispute resolution process).^[17]^[18] The states with a comprehensive approach are California, Connecticut, Florida, Illinois, Maryland, and New York,^[18] as well as Colorado, New Mexico, and Texas.^[17] A 2020 study found that reforms introduced by New York in 2014 successfully reduced out-of-network billing for emergency care by 88%.^[19] Similarly, after Texas enacted an anti-surprise billing law, the Texas Department of Insurance reported receiving up to 95% fewer surprise billing complaints.^[20]^[21]

In states with a law preventing or restricting surprise billing, commercially insured consumers who receive a surprise bill "may be able to obtain assistance from their state Department of Insurance, though state law protections may not cover all surprise billing situations, and may not cover people with insurance through their job."^[22] Consumers who live in states that lack surprise billing protections sometimes negotiate with health care providers to write off a portion of the surprise bill, or for a repayment plan, and sometimes argue to their health insurer for the insurance company to pay a larger proportion of the bill.^[22]

The 2019 Commonwealth Fund report found that federal action was needed to comprehensively protect consumers from balance billing, given that (1) only federal law can comprehensively address patients from one state being treated by providers from another state and (2) federal law currently blocks states from enacting protections against surprise billing from air ambulance services.^[17] Congress gave the issue serious attention in 2018-2019^[23] with both the House and Senate passing substantive bills out of committee in the summer of 2019.^[24]

An American College of Emergency Physicians policy statement on balance billing noted that the Emergency Medical Treatment and Active Labor Act of 1986 requires patients presenting at an emergency department to be treated regardless of insurance coverage or ability to pay as a safety net, and argues that:^[25]

Unfortunately, the claims of physicians who provide emergency care for commercially insured services are often paid by health plans at rates that are substantially below the usual and customary value of these services. In the recent past, most plans based the allowed benefit for these services on the 70th or 80th percentile of usual and customary charges, but the database most often used for this purpose underrepresented these charges. ... In response to successful challenges to such flawed databases, some plans have established out-of-network benefit rates that are still substantially below usual and customary payments. Health plans know that emergency medical care must be provided for their enrollees no matter how poorly the plans pay for these services. The lack of a system to ensure fair benefit payments has allowed payers to underpay the fair value of emergency services, creating an imperative to preserve balance billing. Balance billing ensures the ability to provide patient care services where no enforced laws or regulations require health plans to pay appropriate benefits for emergency care claims at rates sufficient to maintain the financial feasibility of the nation's emergency care system."^[25]

Balance Billing Law. Balance billing is usually legal: When you choose to use a healthcare provider that doesn't have a relationship or contract with your insurer (including ground ambulance charges, even after implementation of the No Surprises Act). According to https://www.healthcare.gov/ Example: A healthcare provider bills $500 to an insurer for a service. The insurance pays $200 and applies $100 to the patient's responsibility for the deductible, coinsurance, or copay. This leaves a remaining balance of $200. If the healthcare provider bills the patient for the remaining $200 balance, this would be considered balance billing.

France

In France, physicians who want to charge more than the government-negotiated set fees are considered to be in a separate "payment sector," which essentially means they are treated as self-employed. They can charge higher fees and receive reduced benefits. In 1987, about 27% of French physicians chose to balance the bill. The percentage is higher for specialists rather than generalists and doctors in urban rather than rural areas.^[26]

Germany

Balance billing is prohibited in Germany. Fee schedules are negotiated between sickness funds and physicians, and physicians are not permitted to charge more than the set amount.^[27]

Japan

Balance billing is prohibited in Japan, and extra fees are only allowed in a small number of circumstances, such as having a hospital bed with extra amenities.^[28]

Taiwan

Balance billing is prohibited in Taiwan, and extra fees have only been allowed recently and in rare defined circumstances. Today, patients in Taiwan are allowed to choose more expensive versions of some devices such as stents, implants or prosthetics, and to pay the difference in cost themselves.^[29]

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References

↑ "Balance Billing - HealthCare.gov Glossary". HealthCare.gov. Retrieved 2019-10-23.
↑ Holahan, John, Lynn Etheredge (1986). Medicare physician payment reform: issues and options. Washington DC: The Urban Institute. p. 109. ISBN 978-0-87766-395-9.{{cite book}}: CS1 maint: multiple names: authors list (link)
1 2 Porter, Michael E., Elizabeth Olmsted Teisberg (2006). Redefining health care: creating value-based competition on results. Boston, Massachusetts: Harvard Business School Press. p. 338. ISBN 978-1-59139-778-6.{{cite book}}: CS1 maint: multiple names: authors list (link)
↑ Bennett, Arnold, Orvill Adams, Families United for Senior Action Foundation (1993). Looking north for health: what we can learn from Canada's health care system. Jossey-Bass/Aha Press Series. p. 173. ISBN 978-1-55542-516-6.{{cite book}}: CS1 maint: multiple names: authors list (link)
↑ McEwen, Nicola (2006). Nationalism and the state: welfare and identity in Scotland and Quebec: Regionalism and Federalism. Brussels, Belgium: P.I.E. Peter Lang SA. pp. 128–9. ISBN 978-90-5201-240-7.
↑ Dunn, Sheilagh M. (1982). The year in review, 1982: intergovernmental relations in Canada. Kingston, Ontario: Institute of Intergovernmental Relations. pp. 180–182. ISBN 978-0-88911-038-0.
↑ Sullivan, Terrence James, Patricia M. Baranek (2002). First do no harm: making sense of Canadian health reform. Toronto, Ontario: Malcolm Lester and Associates. p. 44. ISBN 978-0-7748-1016-6.{{cite book}}: CS1 maint: multiple names: authors list (link)
↑ "Update: Enforcement of Medicare Protection Act provisions (Bill 92) delayed one year". Doctors of BC. March 14, 2019. Retrieved 17 September 2022.
↑ Weisgarber, Maria (2020-09-10). "B.C. Supreme Court rules against legalizing private health care following decade-long battle". British Columbia. Retrieved 2020-09-10.
↑ Woo, Andrea (July 15, 2022). "B.C. Court of Appeal rules against doctor in private health care case". The Globe and Mail. Retrieved September 10, 2022.
↑ Van Horne, Pat (July 20, 2022). "BC Court of Appeal dismisses challenge to Medicare Protection Act". Canadian Health Coalition. Retrieved 17 September 2022.
↑ "balance billing definition". healthinsurance.org. 2017-09-05. Retrieved 2019-04-16. Providers that are in-network have agreed to accept the insurance payment as payment in full (less any applicable copays), and are not allowed to balance bill the patient.
1 2 Sun, Eric C.; Mello, Michelle M.; Moshfegh, Jasmin; Baker, Laurence C. (2019). "Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals". JAMA Internal Medicine. 179 (11): 1543–1550. doi:10.1001/jamainternmed.2019.3451. PMC 6692693 . PMID 31403651.
1 2 Albright, Matthew (October 3, 2018). "Senate Bill and State Balance Billing Laws". Zelis. Archived from the original on 2019-10-02. Retrieved 2019-10-02.
1 2 Garmon, Christopher; Chartock, Benjamin (2017-01-01). "One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills". Health Affairs. 36 (1): 177–181. doi:10.1377/hlthaff.2016.0970. ISSN 0278-2715. PMID 27974361.
1 2 3 4 Karen Pollitz; Matthew Rae; Gary Claxton; Cynthia Cox; Larry Levitt (February 10, 2020). "An examination of surprise medical bills and proposals to protect consumers from them". Peterson-KFF Health System Tracker.
1 2 3 4 5 6 Hoadley, Jack; Lucia, Kevin; Kona, Maanasa (2019). "States Are Taking New Steps to Protect Consumers from Balance Billing, But Federal Action Is Necessary to Fill Gaps" (PDF). To the Point: Quick Takes on Health Care Policy and Practice. Commonwealth Fund. doi:10.26099/jfne-dp10 . Retrieved 2019-11-20.
1 2 Lucia, K; Hoadley, J; Williams, A (June 2017). "Balance Billing by Health Care Providers: Assessing Consumer Protections Across States". Issue Brief (Commonwealth Fund). 16: 1–10. PMID 28613066.
↑ Cooper, Zack; Scott Morton, Fiona; Shekita, Nathan (2020-03-02). "Surprise! Out-of-Network Billing for Emergency Care in the United States" (PDF). Journal of Political Economy. 128 (9): 3626–3677. doi:10.1086/708819. ISSN 0022-3808. S2CID 216209047.
↑ Ashley Lopez, Far Fewer Texans Have Reported Surprise Medical Bills Since New Law Went Into Effect, KUT (July 29, 2020).
↑ Jaie Avila, State says complaints down 95 percent due to new surprise medical bill law, WOAI-TV (July 28, 2020).
1 2 Lee, Christen Linke Young, Matthew Fiedler, Loren Adler, and Sobin (2019-08-01). "What is surprise billing?". Brookings. Retrieved 2019-11-20.{{cite web}}: CS1 maint: multiple names: authors list (link)
↑ "Analyzing New Bipartisan Federal Legislation Limiting Surprise Medical Bills | Health Affairs". www.healthaffairs.org. 2018. doi:10.1377/forefront.20180924.442050.
↑ Albright, Matthew (September 24, 2019). "Unbalanced: Differences between the House & Senate SBB". Zelis. Archived from the original on 2019-10-02. Retrieved 2019-10-02.
1 2 "Policy Statement: Balance Billing". Annals of Emergency Medicine. 68 (3): 401–2. September 2016. doi:10.1016/j.annemergmed.2016.06.034. PMID 27568434.
↑ Thompson, Lawrence H. (1992). Health Care Spending Control: The Experiences of France, Germany & Japan. United States General Accounting Office. p. 40. ISBN 978-0-7881-0574-6.
↑ Thompson, Lawrence H. (1992). Health Care Spending Control: The Experiences of France, Germany & Japan. United States General Accounting Office. p. 41. ISBN 978-0-7881-0574-6.
↑ Ikegami, Naoki, John Creighton Campbell (1996). Containing health care costs in Japan. University of Michigan Press. p. 10. ISBN 978-0-472-10538-0.{{cite book}}: CS1 maint: multiple names: authors list (link)
↑ Okma, Kieke G. H., Luca Crivelli (2009). Six Countries, Six Reform Models: The Healthcare Reform Experience of Israel, The Netherlands, New Zealand, Singapore, Switzerland and Taiwan: Healthcare Reforms "Under the Radar Screen". World Scientific Publishing Company. pp. 179–180. ISBN 978-981-4261-58-6.{{cite book}}: CS1 maint: multiple names: authors list (link)