Jeffrey Wade
In the US, balance billing refers to the practice of out-of-network providers billing patients for the difference between the full amount charged for a service and the amount their health insurance plan covers. In Ohio, patients are protected from balance billing in certain situations, such as when they receive emergency care or are treated by an out-of-network provider at an in-network hospital. In these cases, patients are only responsible for paying their plan's in-network cost-sharing amount, such as copayments, coinsurance, or deductibles. However, patients can give up their protections against balance billing and consent to be charged more in certain situations, such as after receiving emergency care and being stabilized.
| Characteristics | Values |
|---|---|
| Balance billing allowed | Yes, but only in certain circumstances |
| Protection against balance billing | Yes, in Ohio, there are protections against balance billing, especially in emergency services or when treated by an out-of-network provider at an in-network hospital |
| Out-of-network billing | Yes, out-of-network providers may be allowed to bill for the difference between what the insurance plan covers and the full amount charged for a service |
| Surprise billing | Yes, Ohio patients are protected against surprise billing, especially in emergency services |
| Healthcare price transparency | Yes, Ohio has made improvements in this area, with new laws enacted to improve price transparency and prohibit most-favored nation clauses in contracts between providers and insurers |
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What You'll Learn
Balance billing protections for emergency services
In Ohio, patients are protected from balance billing for emergency services under the No Surprises Act. This Act came into effect on January 1, 2022, and protects those with group health plans, group or individual health insurance coverage, or other forms of insurance coverage such as Medicare, Medicaid, or TRICARE, from surprise billing for emergency services.
Surprise billing occurs when a patient receives an unexpected bill from an out-of-network provider or facility. This can happen when a patient receives emergency care and is unable to choose an in-network provider. In the past, a patient's health plan would often not cover the entire out-of-network cost, leaving them with higher costs than if they had seen an in-network provider. This is known as balance billing.
The No Surprises Act bans out-of-network cost-sharing for emergency services and some non-emergency services. It also bans out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers as part of a patient's visit to an in-network facility. Under this Act, patients are only responsible for paying their normal in-network costs, such as coinsurance, copayments, and deductibles.
In Ohio, patients have further protections against balance billing. When receiving emergency care or treatment by an out-of-network provider at an in-network hospital, patients are protected from surprise billing or balance billing. Out-of-network providers cannot balance bill patients without their written consent, and patients are never required to give up their protections from balance billing.
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Protections against surprise billing
In Ohio, there are several protections in place to safeguard patients from surprise or balance billing. Firstly, the federal No Surprises Act (NSA) and the state surprise billing law (HB 388) work together to protect patients from unexpected medical bills. The NSA, which came into effect in January 2022, applies to emergency services, post-emergency stabilization services, and out-of-network non-emergency services provided in but billed separately from a participating facility, such as a hospital or ambulatory surgical center. It limits cost-sharing that patients are required to pay, prohibits balance billing with some exceptions, and mandates that facilities inform patients of their rights and protections against surprise bills.
The state law, HB 388, also protects patients from surprise bills for emergency services and out-of-network services provided at, but billed separately from, an in-network facility. It covers out-of-network ground ambulance services and clinical laboratory services provided in connection with unexpected out-of-network care or emergency services. Under this law, balance billing for out-of-network services at an in-network facility is permitted only if the provider informs the patient that they are out-of-network, provides a good faith estimate of the cost, and obtains the patient's consent to the services.
Additionally, in Ohio, patients have the right to dispute a medical bill if the final charges exceed the good faith estimate by at least $400, provided they file a claim within 120 days of receiving the bill. This dispute resolution process is available to both insured and uninsured individuals, offering further protection against unexpected medical costs.
It is important to note that surprise billing, also known as balance billing, occurs when a patient receives an unexpected balance bill, typically from an out-of-network provider or facility. This can happen when a patient seeks emergency care or is unknowingly treated by an out-of-network provider at an in-network facility. In such cases, the out-of-network provider can bill the patient for the difference between the billed charge and the amount covered by their health plan, resulting in higher costs than anticipated.
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Out-of-network billing
In the context of medical billing, the phrase "out-of-network" is used to describe a situation where a patient sees a provider who is not part of their insurance network. In other words, the provider has not signed a contract with the patient's health plan to provide services at pre-negotiated network rates. This is distinct from "in-network" billing, where agreed-upon rates are established ahead of time between the insurance company and the provider.
When a patient receives treatment from an out-of-network provider, they may be subject to higher costs, a phenomenon known as "balance billing" or "surprise billing." This occurs when the out-of-network provider bills the patient directly at their standard rates, and the patient becomes responsible for paying the difference between the provider's full charge and the amount covered by their insurance plan. This can result in unexpected and substantial medical bills, particularly for emergency services or when patients unknowingly receive treatment from an out-of-network provider.
To address this issue, the No Surprises Act (NSA) was implemented, effective January 1, 2022. The NSA aims to protect patients from surprise billing for emergency services and limit the amount they pay out of pocket for out-of-network services. It establishes an independent dispute resolution process for payment disputes between plans and providers and requires providers to give patients an easy-to-understand notice explaining their billing protections and rights. Additionally, patients must receive notice of and consent to being balance billed by an out-of-network provider.
In Ohio, patients are protected from balance billing in certain situations. For example, when receiving emergency care or treatment from an out-of-network provider at an in-network hospital, patients are protected from surprise billing. They are only responsible for paying their share of the cost, such as copayments, coinsurance, and deductibles, as if the provider were in-network. Patients are also not required to give up their protections from balance billing or to seek care out-of-network.
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In-network billing
When you receive care from an in-network provider, your insurance company has already negotiated rates for various services, which results in lower out-of-pocket costs for you. These costs may include copayments, coinsurance, and deductibles. By staying in-network, you benefit from the discounted rates that your insurance company has arranged on your behalf.
In contrast, when you receive care from an out-of-network provider, they may not have a contract with your insurance company and are not bound by the same pre-negotiated rates. This can result in higher charges, and you may be responsible for the difference between what your insurance covers and the provider's full charge. This is known as "balance billing" or "surprise billing".
To avoid surprise billing, it is generally recommended to seek care from in-network providers whenever possible. However, in emergency situations or when receiving care at an in-network facility, you are protected from balance billing even if an out-of-network provider is involved. This protection is provided by the No Surprises Act, which applies to those with group or individual health insurance plans.
The No Surprises Act also requires healthcare providers and facilities to give you clear information about your billing protections and to obtain your consent before waiving those protections. Additionally, it establishes an independent dispute resolution process if you disagree with your bill, ensuring fair resolution between plans and providers.
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When balance billing is allowed
In Ohio, patients are protected from balance billing or "surprise billing" in certain situations. This includes when they receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center. In these cases, patients are only responsible for paying their in-network cost-sharing amount, such as copayments, coinsurance, and deductibles.
However, there are situations when balance billing is allowed in Ohio. Balance billing can occur when a patient receives care from an out-of-network provider or facility, meaning the provider has not signed a contract with the patient's health plan network. In this case, the out-of-network provider may be permitted to bill the patient for the difference between what the patient's health plan agreed to pay and the full amount charged for the service. This amount is typically higher than the in-network costs for the same service and may not count towards the patient's annual out-of-pocket limit.
Surprise billing can also occur when a patient cannot control who is involved in their care. For example, during an emergency or when the patient schedules a visit at an in-network facility but is unexpectedly treated by an out-of-network provider. In these cases, the out-of-network provider can bill the patient, but only up to the patient's plan's in-network cost-sharing amount.
Additionally, even when receiving care at an in-network hospital, certain providers may be out-of-network. In these cases, the out-of-network providers cannot balance bill the patient for specific services, including emergency medicine, anesthesiology, pathology, radiology, laboratory services, neonatology, assistant surgeons, and hospitalists or intensivists. However, if the patient gives written consent and agrees to give up their protections, out-of-network providers can balance bill them for other services received at in-network facilities.
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Frequently asked questions
Balance billing is when an out-of-network provider bills you for the difference between what your insurance plan agreed to pay and the full amount charged for a service.
Ohio does not allow balance billing for emergency services or for treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center.
Out-of-network refers to providers and facilities that have not signed a contract with your health insurance plan.
You have protections against surprise billing in Ohio. You are only responsible for paying your share of the cost (like copayments, coinsurance, and deductibles) that you would pay if the provider or facility was in-network.
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