Patient billing: when is it illegal to balance bill.

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!

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