In-network providers generally cannot balance bill patients. When a healthcare provider participates in an insurance network, they agree to accept the insurer’s contracted rates as payment in full for covered services. This means that the provider cannot charge patients for the difference between their usual fees and the lower rates negotiated with the insurer. An in-network provider balance bill occurs when a patient receives a bill from a healthcare provider who is supposed to be in their insurance network, but the bill is higher than what the insurance company has agreed to pay the provider. This happens when the provider bills the patient for the difference between what the insurance company pays and what the provider believes they are owed.
For example, let’s say a patient goes to an in-network hospital for a procedure that costs $10,000. The insurance company has negotiated a rate with the hospital for $8,000. The hospital bills the insurance company $8,000 but then bills the patient an additional $2,000 to cover the difference. This is a balance bill, and it’s an issue that can be very frustrating and expensive for patients. Balance billing is most commonly associated with emergency room visits or out-of-network providers, but it can also happen with in-network providers. It can occur when the provider feels that the insurance company’s payment is not enough to cover the costs of the services provided, or when the provider disagrees with the insurance company’s determination of what is covered under the patient’s plan.
In-Network Provider can Balance Bill
As mentioned above, in-network providers are healthcare providers who have agreed to accept the negotiated rates set by an insurance company. However, there are cases where in-network providers may balance bill their patients, which can result in unexpected and costly medical bills.
Following are some examples of when an in-network provider may balance bill their patient:
- Emergency room visits: Emergency room doctors may be out-of-network even if the hospital is in-network. This means that patients who receive emergency care from an out-of-network doctor may be balance billed.
- Anesthesiologists: Anesthesiologists may be out of network even if the hospital or surgeon is in-network. This means that patients who receive anesthesia from an out-of-network provider may be balance billed.
- Radiologists: Radiologists may be out of network even if the hospital or doctor is in-network. This means that patients who receive radiology services from an out-of-network provider may be balance billed.
- Lab tests: Some lab tests may be performed by out-of-network providers, even if the doctor or hospital is in-network. This means that patients who receive lab tests from an out-of-network provider may be balance billed.
- Out-of-network referrals: In some cases, an in-network provider may refer a patient to an out-of-network provider for specialized care. This means that patients who receive care from an out-of-network provider may be balance billed.
We hope this article might have cleared the confusion about can in-network provider balance bill? It’s important to note that balance billing is generally considered a controversial practice, as it can leave patients with unexpected medical bills and financial hardship. Some states have laws that protect patients from balance billing in certain situations, such as emergency care or when a patient receives care from an out-of-network provider without their knowledge or consent. It’s important to note that balance billing laws vary by state and type of insurance plan.
About Medical Billers and Coders (MBC)
Medical Billers and Coders (MBC) is a leading revenue cycle management company providing complete medical billing and coding services. We can assist you in receiving accurate insurance reimbursements whether you are in-network or billing as an out-of-network provider. Even we can assist you in getting credentialed with various insurance companies in your area.
Our credentialing team consists of experienced professionals who can assist with provider enrollment, primary source verification, and other aspects of the credentialing process. To know more about our medical billing and coding services including provider credentialing and enrollment, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.
FAQs
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What does it mean for a provider to be in-network?
An in-network provider is a healthcare provider who has agreed to accept negotiated rates from an insurance company as full payment for covered services.
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Can in-network providers balance bill patients?
Generally, in-network providers cannot balance bill patients. They must accept the insurance company’s payment as full. However, balance billing can still occur in certain situations, such as emergency services or when out-of-network specialists are involved.
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What is balance billing?
Balance billing happens when a healthcare provider bills a patient for the difference between their usual fee and the lower rate agreed upon with the insurance company.
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When might a patient receive a balance bill from an in-network provider?
Patients might receive a balance bill if they receive services from an out-of-network provider at an in-network facility, such as emergency room doctors, anesthesiologists, or radiologists.
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Why are some medical professionals out-of-network even if the hospital is in-network?
Some specialists like anesthesiologists or radiologists may not be part of the same network as the hospital, leading to balance billing for their services.
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Are there laws protecting patients from balance billing?
Yes, some states have laws that protect patients from balance billing in certain cases, such as during emergency care or when patients unknowingly receive out-of-network services.
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How can I avoid balance billing?
Patients can reduce the risk of balance billing by verifying whether all providers involved in their care, including specialists, are in-network, or by seeking assistance from their insurance provider.
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What should I do if I receive a balance bill?
If you receive a balance bill, you should contact your insurance company or the provider to understand the charges and see if they can be negotiated or appealed.
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How can Medical Billers and Coders (MBC) help with balance billing?
MBC can assist both in-network and out-of-network providers with accurate billing and credentialing to help minimize balance billing issues and ensure proper reimbursements.
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What services does MBC provide for credentialing?
MBC’s credentialing team helps with provider enrollment, primary source verification, and other aspects of the credentialing process, ensuring smooth collaboration with insurance companies.
