As if anything to do with insurance isn’t hard enough to understand, things like healthcare billing certainly make it so. Policyholders commonly experience “balanced billing,” and getting one from a hospital ER, for example, might not be anything like you’d expect.
Common health insurance policy types – HMO and PPO plans – work within specific networks of healthcare providers to provide lower premiums. Unfortunately, even when visiting an in-network hospital, the doctor or surgeon who treated you may not be part of the same network.
After visiting a hospital, clinic, or any medical facility operating outside of your health insurance network, you may receive a bill for the difference owed after your health insurance has paid its share of the medical provider’s invoice.
For example, if you have a visit to a hospital emergency room (ER), you might receive a bill that looks a bit like this:
The hospital charges your insurance carrier $500 for an ER visit. The insurance pays $250. You don’t pay anything additional because the hospital is in a network contract with your insurance provider. You’re only responsible for co-insurance and co-pay amounts less your deductible.
A treating doctor also charges $500 for your ER visit. Insurance pays $250. Because the treating doctor hasn’t a contract with your insurance provider, you’re responsible for the additional $250.
To avoid “balanced billing”, ask your insurance agent which healthcare providers are in your policy’s provider network, so you can go to network providers wherever possible.
If you need health insurance, don’t feel as though you can buy coverage only through the government’s website or any of the third parties soliciting consumers. The insurance agent you have always worked with (and who is familiar with your individual situation) can answer your questions about healthcare reform and help you compare coverage. You also can purchase a plan through him or her.