Many providers are unsure as to what balance billing actually means.
Balance billing, simply put, is billing a patient for an amount not paid by the insurance plan, the difference between the billed amount and the amount allowed for a covered service by the patient’s plan.
Guidelines state that if a provider has entered into a contract with an insurance plan, then he/she would not legally be able to bill a patient for any amount not allowed on a covered service. The provider may certainly collect from the patient co-pays, co-insurance, and deductible amounts. A provider cannot bill a patient for any amount not specifically stated by the patient’s insurance plan as being their responsibility.
If a provider does not have a contract in place with a patient’s plan, then it is perfectly legal to bill the patient according to the practice’s fee schedule or rates. Also, a provider may bill a patient for any non-covered services or in the event that the patient chooses to opt-out of insurance billing and has chosen the self-pay route.
Be in the know and and always be sure to follow CMS guidelines. Discuss the options with your patients up front and maximize your revenue!