When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or surgical center, you are shielded from balance or surprise billing. In such cases, you’ll only be responsible for your plan’s in-network costs, such as copayments, coinsurance, and deductibles. At Frank Lalezar, MD, we are committed to providing exceptional care and transparency regarding your financial responsibilities.
What Is Balance Billing?
When you receive care from a healthcare provider, you may be responsible for out-of-pocket expenses such as copayments, coinsurance, or deductibles. These are costs associated with your health insurance plan.
However, if you receive care from a provider or visit a facility outside your plan’s network, you might face additional charges or be required to pay the entire bill. These unexpected costs can create significant financial strain.
Out-of-network providers and facilities are those that do not have a contract with your insurance plan to provide services at negotiated rates. In these cases, they may charge you the difference between what your insurance pays and the total cost of the service. This practice is known as balance billing. These charges are often much higher than in-network rates and may not count toward your deductible or out-of-pocket maximum.
A surprise bill occurs when you unknowingly receive care from an out-of-network provider, often in situations beyond your control. This can happen during emergencies or when an out-of-network provider is involved in your care at an in-network hospital or surgical center. These surprise bills can amount to thousands of dollars, depending on the services provided.
You Are Protected From Surprise Billing for These Services…
Emergency Services
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Services Referred by Your In-Network Doctor
If your in-network doctor refers you to an out-of-network provider without your consent, the out-of-network provider cannot balance bill you. This applies to services such as laboratory tests, pathology, or imaging studies.
For patients with insurance marked as “fully insured coverage,” the full range of protections applies. You may need to complete a form to ensure your balance billing protections are enforced.
Certain Services at In-Network Hospitals or Surgical Centers
When you visit an in-network hospital or ambulatory surgical center, some of the services you receive might be provided by out-of-network providers. These can include specialties like emergency medicine, anesthesia, radiology, pathology, neonatology, laboratory, or hospitalist care. In such cases, you are only required to pay your in-network cost-sharing amounts. Out-of-network providers cannot balance bill you for these services, nor can they request that you waive your protections.
Additional Protections Against Balance Billing
When balance billing is not allowed, you also benefit from the following safeguards:
- You are responsible only for your in-network cost-sharing amounts (copayments, coinsurance, and deductibles).
- Your health plan is required to pay the remainder of the costs directly to the out-of-network provider or facility.
- Emergency services must be covered without requiring prior authorization from your health plan.
- Out-of-network emergency services must be treated as if they were in-network, meaning your cost-sharing amounts will align with in-network rates.
- Any payments you make for emergency or out-of-network services must be counted toward your in-network deductible and out-of-pocket maximum.
You Do Not Have to Waive Your Rights
You are never obligated to give up your protections from balance billing. Additionally, you have the right to choose in-network providers and facilities for your care. If an out-of-network provider requests written consent to balance bill you, you have the option to decline and ensure your protections remain intact.
