When you need and receive emergency care or treatment by a provider outside of your network at an in-network ambulatory surgical center or hospital, you have protection from what is called surprise or balance billing.  What is balance billing?

When you see a healthcare provider, you may accrue costs via a copayment or deductible. If you’re receiving care from a provider or at a facility that is out-of-network for your insurance plan, you may be liable for additional costs or even the entire bill. What does out-of-network mean? Out-of-network pertains to facilities, providers, and other healthcare professionals who do not have a signed contract with your health insurance plan. In the event that you receive care from outside your network, you may be responsible for the remainder of the cost of the service after your insurance has been applied to the total bill. This is called balance billing. This cost likely exceeds the cost for the same service at an in-network facility and might not count toward your yearly out-of-pocket limit. Surprise billing is when you receive an unexpected bill resulting from a balance not covered by your insurance plan. Surprise billing may be the result of needing emergency care but not having access to an in-network provider or facility.

When are you protected from balance billing?

Emergency Services

If you receive emergency services from an out-of-network facility or provider for an emergency condition, the most you will be responsible for paying for is your plan’s in-network copayments, coinsurance, or other costs. You cannot receive a balance bill for these emergency services, including any additional treatment you may receive after your condition is stabilized. However, this can change if you concede your protections against being balance billed via written consent for these supplemental services. 

Select Services Received at an In-Network Ambulatory Surgical Center or Hospital 

When receiving treatments or services at an in-network facility, there is a chance that the provider administering treatment is out-of-network. If this is the case, the most these providers will hold you accountable for is the in-network costs, such as a coinsurance or copayment. Applicable services and treatments include emergency medicine, anesthesia, hospitalist, pathology, radiology, neonatology, intensivist, laboratory, and assistant surgeon services. Not only can these providers not give you a balance bill, but they most likely will not ask you to concede your protections against being balance billed. If you receive additional services or treatment at these facilities, you cannot receive a balance bill unless you give up your protections by giving written consent to receive a balance bill. You are never required to receive out-of-network care or sacrifice your right to not receive a balance bill. You always have the right to choose to receive care from an in-network facility or provider. 

What additional protections do you have if you are unable to receive a balance bill? If you are not eligible for balance billing, you are only entitled to pay your share of the in-network copayments, coinsurance, and/or deductibles associated with your health plan. The out-of-network facilities and providers will be compensated directly by your insurance plan. 

What Your Health Plan is Responsible For

Your health plan covers emergency services without pre-approval.
Your health plan covers receiving treatment from out-of-network providers. 

Your health plan bases cost-sharing with out-of-network providers on the cost of receiving the same treatment with an in-network provider or facility. You will find this breakdown in your explanation of benefits.
Your health plan allocates any amount you pay for out-of-network or emergency services toward your annual out-of-pocket limit and deductible. 

Do you believe you have been wrongly billed? Please visit 8262 Point Meadows Drive, Suite 101 Jacksonville, FL 32256 or call (904) 265-4310.