Balance billing refers to the billing practice where a healthcare provider bills a patient for the difference between the total cost of a medical service and the amount covered by the patient’s insurance plan.
Healthcare providers who do not have a contractual agreement with a specific insurance plan are considered out-of-network. When a patient seeks services from such providers, they may be vulnerable to balance billing.
The maximum amount an insurance company is willing to pay for a particular medical service. Any costs beyond this allowed amount may result in balance billing for the patient.
A document sent by the insurance company to the policyholder that outlines the costs, coverage, and payments made for a particular healthcare service. It helps patients understand how much they might be responsible for in terms of balance billing.
Healthcare providers who have agreements with a specific insurance plan to provide services at pre-negotiated rates. Patients are generally protected from excessive balance billing when utilizing in-network providers.
A situation where patients receive unexpected bills from out-of-network providers, often occurring when patients receive emergency care or use ancillary services, even in an in-network facility.
The standard charges for medical services in a specific geographic area. Insurance companies may use UCR charges to determine the allowed amount for out-of-network services, impacting the potential for balance billing.
The agreed-upon rate between an insurance company and an in-network provider for specific medical services. This rate helps determine the patient’s financial responsibility and mitigates the risk of balance billing.
Services or treatments that are essential for the diagnosis, treatment, and prevention of illness or injury, as determined by healthcare professionals. Insurance coverage and the potential for balance billing often hinge on the medical necessity of a service.
Legal measures and regulations implemented to protect patients from excessive balance billing, such as laws prohibiting surprise billing or capping the amount a provider can charge for out-of-network services.