Alyssa Lane
There are a variety of reasons why a medical practice may not bill insurance. Firstly, some doctors and medical practices are considered out-of-network, meaning they are not part of the patient's health insurance plan network. In these cases, the patient will be billed for any charges that the insurance company does not cover. Secondly, some doctors and medical practices do not accept insurance at all and require cash payments from patients, which can result in unexpected medical bills. This trend is known as the direct primary care movement, where physicians opt out of traditional insurance-based healthcare models. Additionally, surprise medical bills can occur when a patient is treated by an out-of-network provider at an in-network facility, or when referred to an out-of-network provider by an in-network doctor. Patients have certain rights and protections against surprise medical bills, and can dispute or file a complaint about these bills.
| Characteristics | Values |
|---|---|
| Federal law | Protects patients from out-of-network bills for emergency services in hospitals, hospital outpatient departments, and independent, freestanding emergency departments |
| Surprise bill | When an out-of-network provider treats a patient at an in-network hospital or ambulatory surgical center |
| No Surprises Act | A federal law that went into effect on January 1, 2022, protecting patients from unexpected out-of-network medical bills |
| Medical billing advocate | Can help reduce costs by identifying abusive, fraudulent, or erroneous billing practices |
| Managed care plan | Most Americans with health insurance have a managed care plan, which provides information on in-network healthcare providers and facilities |
| In-network | If a healthcare provider is in-network with the patient's insurance plan, the patient doesn't have to pay anything extra |
| Out-of-network | If a healthcare provider is out-of-network, the patient will be billed for the amount that the insurance company does not pay |
| Claim denial | If a claim is denied, the insurance company must notify the patient in writing and provide information about the appeals process |
| Billing errors | Medical billing is complex and error-prone, so patients should call their healthcare provider and insurance company to rectify any errors |
| Surprise bill protections | Apply to emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services |
| Self-insured coverage | Some employers or unions provide self-insured coverage that is not subject to state law |
| Out-of-network consent | Patients must be given the opportunity to choose an in-network provider at least 72 hours in advance of services; if they sign a consent form for out-of-network care, they may lose billing protections |
| Direct primary care | A growing movement where physicians opt out of traditional healthcare models that rely on insurance, instead requiring cash payments from patients |
| Cash-only doctors | Doctors who do not accept insurance and require cash payments; they are not required to accept insurance plans or the rates set by insurance companies |
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What You'll Learn
Doctors who don't accept insurance
A small but growing number of doctors are choosing to opt out of working with insurance companies, instead dealing directly with patients. This trend is part of the growing direct primary care movement, where physicians reject traditional healthcare models that rely heavily on insurance.
There are several reasons why a doctor may choose to reject insurance. Firstly, insurance companies often don't reimburse doctors enough to cover the costs of longer visits, and there is a lot of paperwork and administrative burden involved in dealing with insurance companies. This can result in doctors having to see more patients to make ends meet, reducing the quality of care and the time spent with each patient.
Secondly, insurance companies often deny coverage of certain medications or tests that doctors recommend, creating an appeal process that is time-consuming and frustrating for doctors. Additionally, insurance companies may lower reimbursement rates, forcing doctors to see even more patients to maintain their income.
If your doctor doesn't accept your insurance, you have several options. You can try to get out-of-network coverage or find an in-network provider. You could also ask if the doctor will take a reduced fee or provide flexible payment terms. Alternatively, you could work with a medical billing advocate who can help reduce your costs by identifying errors in billing and negotiating with healthcare providers.
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Surprise medical bills
In the United States, the No Surprises Act, which came into effect on January 1, 2022, offers protection against surprise medical bills for individuals with group or individual health plans. This federal law applies to most types of health insurance and shields individuals from unexpected out-of-network medical bills, including non-emergency care at in-network facilities and services from out-of-network air ambulance providers.
If patients receive a surprise medical bill, they can take several actions. Firstly, they should contact their insurance company and healthcare provider to rectify any potential errors in the billing. Secondly, they can work with a medical billing advocate who can identify erroneous charges and negotiate with healthcare providers on the patient's behalf. Additionally, if the final charges exceed the good-faith estimate by at least $400, patients have the right to dispute the charges by filing a claim within 120 days of receiving the bill.
It is important to note that surprise bill protections typically apply to specific medical specialties, such as emergency medicine, anesthesiology, pathology, radiology, and laboratory services, even if the patient receives written notice that the provider is out-of-network. Moreover, consumers in New York are protected from surprise bills when treated by an out-of-network provider within their health plan's network, including emergency services and referrals to non-participating providers.
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Billing errors
There are several common billing errors that medical practices should be aware of and take steps to prevent. One such error is incorrect data entry, which can include input errors such as transposed dates, incorrect insurance policy numbers, or inaccurate patient information. To mitigate this risk, practices should ensure that patient data is accurately entered and maintained in electronic health record (EHR) systems, reducing the potential for errors. Additionally, having patients complete forms online can increase the accuracy of information.
Another common error is a lack of understanding of payer policies, which can lead to claims being rejected or denied. Medical practices should stay up-to-date with coding and billing updates and conduct regular training to ensure compliance with payer policies. Understanding the bundling rules and regularly reviewing guidelines can also help prevent errors. For example, billing for multiple procedures separately when they should be billed under a single code can be avoided by following the correct bundling rules.
Upcoding is another issue that can lead to audits and legal consequences. This involves using a higher-level code than justified to maximize reimbursement. Implementing checks and balances in the billing process can help identify and rectify discrepancies between services rendered and billed. Regular audits and reviews of medical billing errors can help identify patterns and address issues promptly.
Furthermore, billing errors can occur when services provided are not billed due to oversight or miscommunication. To prevent this, medical practices should ensure effective communication between the medical team and the billing department. Additionally, billing codes should be regularly reviewed to ensure they accurately reflect the services provided. If errors occur, practices should address them with staff to ensure they are corrected and not repeated.
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Negotiating payment terms
- Start Early: It is important to start the negotiation process as early as possible. Contact the billing department, your healthcare provider's billing agency, and your health insurance company as soon as you receive a bill or an Explanation of Benefits (EOB). Medical debt is treated differently than other types of debt, and you have more flexibility before it goes to a debt collector.
- Review and Dispute Errors: Carefully review your medical bill for any errors or discrepancies. Compare the charges on your bill with those listed on your EOB, which outlines the cost of your services, including how much your insurance covers and your expected out-of-pocket expenses. If you identify any mistakes or unexpected charges, contact the billing office and request them to recode and re-bill your insurer.
- Understand Your Insurance Coverage: Familiarize yourself with your health insurance plan's coverage and network of in-network providers. In-network providers have agreed-upon rates with your insurer, and you are typically responsible for lower out-of-pocket costs. If you visit an out-of-network provider, you may be billed for charges not covered by your insurance. Always verify that your healthcare provider is in-network before receiving treatment.
- Negotiate Directly with the Healthcare Provider: Contact your healthcare provider or hospital directly and ask to negotiate a lower bill or a payment plan. Hospitals often have financial assistance programs for low-income patients, and some providers offer discounts for uninsured patients. You can also explore options like medical credit cards, which offer lower interest rates, allowing you to pay for your medical costs over time.
- Seek Professional Help: Consider working with a medical billing advocate who can assist in identifying erroneous or fraudulent billing practices and negotiate on your behalf. They can provide valuable expertise in navigating the complex world of medical billing and insurance. Additionally, patient advocacy groups often have resources and programs to help individuals facing financial burdens due to medical expenses.
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Consumer protections
The Act ensures that providers must give a good faith estimate of the cost of care if requested by the patient or when scheduling services at least three business days in advance. This estimate can be disputed if the final bill exceeds the estimate by a significant amount. Additionally, the law specifies that out-of-network providers cannot bill patients for excess charges and must not hold them liable for more than the in-network cost-sharing amount. This provision puts the onus on out-of-network providers to determine a patient's insurance status and applicable cost-sharing.
In the state of New York, consumers are protected from surprise bills when treated by an out-of-network provider within their health plan's network. This includes protection from bills for emergency services in hospitals and inpatient care following emergency room treatment. Patients must also be given a meaningful opportunity to choose an in-network provider in advance, and surprise bill protections typically apply to specific specialties, such as emergency medicine, anesthesiology, pathology, and radiology.
To address concerns about medical billing and collections, the Consumer Financial Protection Bureau (CFPB) released a bulletin reminding debt collectors and credit reporting companies of their legal obligations under the Fair Debt Collection Practices Act and Fair Credit Reporting Act for bills covered by the No Surprises Act. If consumers believe their rights are being violated, they can contact the Centers for Medicare & Medicaid Services No Surprises Help Desk or submit a complaint to the CFPB. Additionally, working with a medical billing advocate can help identify erroneous billing practices and negotiate with healthcare providers.
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Frequently asked questions
A surprise bill happens when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center, or you are referred by an in-network doctor to an out-of-network provider.
If you receive a surprise bill for medical services provided after July 1, 2017, and have already paid more than your in-network cost share, file a complaint with your health insurer with a copy of the bill.
The No Surprises Act is a federal law that went into effect on January 1, 2022. It protects consumers from surprise medical bills when they get non-emergency services at an in-network facility and receive care from an out-of-network provider without their consent.
You can work with a medical billing advocate to reduce your costs by identifying abusive, fraudulent, or erroneous billing practices. You can also try to negotiate payment terms with your healthcare provider or switch to a different insurance policy.
An out-of-network provider is a healthcare provider that is not part of your health insurance plan's network. Out-of-network providers typically charge higher rates than in-network providers, and your insurance company may not cover the full cost of their services.
