- Usually this occurs when a consumer inadvertently sees an out-of-network provider in an emergency situation
- Because insurers do not pay out-of-network providers the full amount of the service charges, some providers try to collect from the patients the remaining amount of their fees.
Why is this important?
About 1 in 5 Mississippi adults has medical debt in collections, meaning their past due medical debt has been sold to collection agencies. Once a collection agency is involved, the debt can harm a person’s credit score.
A patient receives treatment at the Emergency Department at a hospital that participates in his insurance company’s network. The total cost of treatment is $100 ($30 in hospital fees and $70 for physician fees). The total cost of treatment is submitted to the patient’s insurance company. Insurance pays the in-network hospital fees ($30), but the physician that treated the patient was not a Hospital employee and does not participate in the insurance network. Because the physician is not in-network and there is no assignment to pay him directly, the insurance company will send the patient the in-network physician fee amount ($50) which is a discounted rate.
Even though the hospital was in the patient’s network, the physician was not. The patient will receive a $70 bill from the physician for the full amount of his fees. This is a “Balance Bill” - where a healthcare provider bills a patient for the amount of fees that insurance did not cover.
A patient visits his usual physician who participates in the patient’s insurance network. The physician orders blood work and sends the patient’s sample to an out-of-network laboratory for testing. The patient’s insurance covers 50% of out-of-network care. The lab’s total charges are $500, and the insurance network rate is $300. The patient’s insurance pays $150, which is 50% of the network rate, and expects the patient to pay the remaining $150 as outlined in the patient’s policy. But the lab adds on the $200 difference between its charge ($500) and the network rate ($300) to the bill sent to the patient.
Even though the physician was in the patient’s network, the laboratory was not. The patient receives a bill of $350 from the lab - the $150 usual co-pay plus the $200 (balance) bill for the different rate. This is a “Balance Bill” - where a healthcare provider bills a patient for the amount of fees or charges that insurance does not cover.
Under this law, if a healthcare provider accepts a patient’s insurance assignment, then the insurance company will pay the provider directly for the patient’s treatment.
That payment is considered payment in full to the healthcare provider - this means the provider cannot bill the patient later for any amount more than the payment received from the insurance company, other than normal deductibles or co-pays.
So, in Example 2 above, if the provider (the lab) had accepted the assignment, it could not have billed the patient for the $200 difference.
Assignment means that your physician agrees to accept your insurance company’s rates as full payment for services covered by insurance.
What can I do if I get a surprise balance bill?
- Make sure it is a Balance Bill (remember your co-pays and deductibles)
- Call your insurance company to make sure it’s not a mistake and that the provider has accepted Assignment
- Call the Insurance Department at 1-800-562-2957 or contact us here
- Call the Attorney General’s Office - Consumer Protection Division at 601-359-4230 or file a complaint
- Call the Mississippi Health Advocacy Program at 601-353-0845
- File a claim in court
- Contact a private attorney
The Insurance Department enforces the law to protect consumers against surprise balance billing.