When you receive a medical bill for a balance – even though you’ve already paid your deductible, coinsurance, or copayment- you might be wondering where the charges are coming from. Then you’ll wonder why you, not your insurance, are responsible for paying it.

Even in an in-network facility or hospital you can be responsible for those charges. For example, if you see radiologist who doesn’t have a contract with your insurance provider, they can charge you however much they want and can balance bill. This is referred to as “surprise” balance billing.

Oregon is one of the latest states to prohibit this practice, referred to as “surprise” balance billing. But what is balance billing?

When the hospital bills you for the remaining balance after you’ve paid your deductible, coinsurance, or copayment, and your insurance has paid everything it’s required to toward your medical bill, you’re being balance billed.

You are being balance billed because:

  • Your insurance, medicare, or medicaid does not have a contract with your healthcare provider. This either happens because you’re out of network or because of concierge medical practices.
  • The service you’re being billed for is not covered by your health insurance policy. This happens with services not medically necessary, like cosmetic services. You would cover the entire bill in this case.

However, medicare, medicaid, and some insurances have specific clauses/agreements that prohibit balance billing. That means if your health care provider accepts Medicare assignment, Medicaid, or has a contract with your insurance and is billing you more than the contract allows, you shouldn’t be balance billed. In these cases the health care provider has agreed that your payment (coinsurance or copayment) is your payment in full. So balance billing is considered illegal.

This is the basics of balance billing, but the legality of balance billing also is up to individual state policies.

Oregon passed a law March 2018 that protects citizens from “surprise” out-of-network medical bills from health care providers that were not chosen by the consumer. This law will protect from balance billing services on or after March 1, 2018.

In cases of emergency, it is especially difficult, or not possible, to choose a health care provider that is in network. This law would protect from surprise bills that arise from those situations.

It also requires health care providers that are out of network to make it known to the consumer of increased financial responsibility. One can still choose to see out-of-network providers and the provider can still balance bill their customers, but it makes the process more transparent.