Balance billing occurs when a health care provider bills a patient after the patient’s health insurance company has paid its portion. The balance bill is for the difference between the amount the provider charges and the price the insurance company sets, after the patient pays any co-pay, co-insurance, or deductible.
Balance billing can occur when a consumer receives health care services from an out-of-network provider or an out-of-network facility. In-network providers agree with an insurance company to accept the insurance payment in full. In-network providers agree not to balance bill. Out-of-network providers do not have this agreement with the insurance company. Therefore, in the past they sometimes billed the patient for the amount not covered by insurance.
Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (POS) plans, offer some coverage for out-of-network care, but the provider can still balance bill the patient. Other plans offer no coverage for out-of-network providers and leave the financial responsibility entirely on the consumer.
Balance billing is prohibited in both Medicare and Medicaid.
Surprise billing occurs when a patient receives a balance bill after unknowingly receiving care from an out-of-network provider or an out-of-network facility, such as a hospital. This can occur in emergency and non-emergency situations.
Some states have enacted protections for consumers against surprise billing. However, state laws do not apply to self-insured health plans, which account for the majority of people who get coverage through an employer. Now, federal law adds additional protections.
A new federal law, the No Surprises Act, protects you from:
The federal law applies to plans starting in 2022 and will be enforced by the federal government in Indiana. It applies to self-insured health plans offered by employers as well as health insurance companies.
This is true even if the emergency services you received were at an out-of-network facility or performed by an out-of-network provider.
FAQs with Examples of the No Surprise Act Protections
Please fill out this form, and we will contact you during the next business day to schedule your appointment.
For medical emergencies, call 911. Please do not submit urgent or time-sensitive requests through this form. Please call the office at (260) 436-7205.
Please provide a phone number in the following format: 123-123-1234
We will use your contact information provided to get in touch with you during the next business day (Monday through Friday) to schedule your appointment.
Thank you,Ophthalmology Consultants of Fort Wayne
Please call (260) 436-7205 option #2, to make your payment. Once you’ve made your payment, we will process your order and contact you when your contacts are ready for pick-up in about 14 days.
Please call (260) 436-7205 option #2, to make your payment. Once you’ve made your payment, we will process your order and contact you when your contacts are ready for shipping.