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Balance Billing for Out of Network Providers

Balance billing may require tools to calculate.‘Balance billing’ refers to a system in which doctors from out-of-network (OON) medical facilities can bill a patient for any remaining costs after being paid by the insurance provider. An OON medical office is not bound by the contractual agreements of being in-network. If you are a manager of a clinic or are responsible for billing collections, you probably already understand this balance billing process.

Unfortunately, approximately 63% of adults in the United States have received at least one medical bill that costed more than expected, according to a 2014 NerdWallet study. Say, for instance, a patient has a $2,000 bill and the out-of-network insurance covers 50%. The general public estimates that $1,000 will therefore be covered by the insurance provider, when in actuality it might only be $400.

As a medical facility, it’s important to not only understand this problem but also educate the public on balance billing for better patient care and relations. Here are a few points to share with the public, particularly OON patients that come through the door:

  • In-Network vs. Out-of-Network: An in-network insurance provider agrees to offer rates at a discount to patients. Medical practices outside of a network follow no guidelines or restrictions in terms of payment for service. They can charge full price, and they will.
  • The Insurance Limit: An insurance company only “allows” a certain amount toward OON coverage. This limit varies and is not always easy to see in documentation, but it does exist. For the above example, the patient had an $800 limit for OON coverage, of which the insurance provider paid their willing $400.
  • Check the Math: Medical clinics and insurance providers can make mistakes. Compare your itemized bill from the medical provider with an EOB (explanation of benefits) statement from your health insurance provider. Look for incorrect service charges and dates, double charging, and upcoding. If there are mistakes, talk to the medical practice and/or your insurance provider immediately. In the long run, this helps everyone.
  • Pay on Time: Balance billing can be a pain. Knowing your insurance network and limit help considerably. That way, you know what to expect on your bill and how to plan ahead to pay it off on time. Failure in doing so could result in harming your credit.

Accentuating and educating these few points about balance billing and out-of-network treatment can help establish a positive patient perspective. The more they know, the less likely they are to become upset and delinquent on payments (whether on purpose or due to financial strain).

If your clinic has its hands tied and struggles to collect unpaid medical bills, a third-party agency like Billing Advantage might be able to help. Billing Advantage is a trusted and experienced team of collections specialists that understands the importance of data security and HIPAA compliance, leaving your medical team free to serve patients’ needs with less stress. Contact us today to get started!


Donna Whipple Donna Whipple

Donna Whipple, Psy.D. is a clinical psychologist with over 30 years of management experience. She has particular interest and expertise in HIPAA and ethical treatment and business practices in a changing high tech industry. She has a particular talent in boiling down complex regulations so providers can understand and comply with them. As co-owner of Billing Advantage Inc., Donna is involved in all aspects of the company but her particular contributions to the business is in mentoring upper level managers and helping them be more effective in their leadership.


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