What is Surprise Billing Also Known As Balance Billing?

Indianapolis Eastside Motorcycle Accident Lawyer

  • Most health insurance plans distinguish between in-network and out-of-network medical providers and pay them accordingly.
  • A large number of plans pay a lesser amount to out-of-network providers
  • Some plans may not reimburse out-of-network providers
  • Surprise billing is the unpaid balance for services rendered by an out-of-network provider after the patient’s healthcare plan pays their portion, if any, of the provider’s bill.
  • A patient may receive a surprise statement when an in-network facility contracts with out-of-network ancillary providers.
  • Ancillary providers may include surgeons, anesthesiologists, radiologists, pathologists, and others.
  • Patients receiving emergency care for injuries received in an accident, may receive a surprise balance bill by out-of-network providers and should discuss these charges with their Indianapolis eastside motorcycle accident lawyer
  • Emergency air-transport services are federally regulated by the Airline Deregulation Act of 1978
  • It is unknown at this time how far federal legislation will go to protect the pockets of Indiana accident victims treated or transported by out-of-network facilities and medical providers
  • The state of Indiana passed legislation against surprise billing in 2020, but failed to include protections for accident victims who were transported or unwittingly treated by out-of-network providers.

Indianapolis Eastside Motorcycle Accident LawyerNo doubt by now you have heard about a practice known as Surprise Billing, commonly known as Balance Billing. The term surprise billing accurately describes a patient billing generated by an out-of-network treating healthcare provider, most notably for treatment received in an emergency facility after an automobile crash, trucking collision, or motorcycle accident. “We see this all the time in our law practice, states Indianapolis eastside motorcycle accident lawyer Charlie Ward, when our clients, critically injured in a vehicular crash, have been transported and/or treated in trauma centers across Indiana.” But accident victims are not the only patients that may receive a surprise billing in the mail. 

What is surprise billing? First, let me explain a bit about healthcare benefits and how they may be applied to your medical bills.

What is an Explanation of Benefits (EOB)?

An Explanation of Benefits commonly referred to as an EOB is a statement from the health insurer, (group, individual, Medicare, etc.) listing charges and benefits paid for medical services rendered to the patient. The EOB will reflect any healthcare provider discounts contractually required, co-pays received, insurance payments made to the provider (if any), along with any balance you might owe for the provider’s services. If you have not yet met your annual deductible, this too will be taken into consideration and factored into the amount you owe to the healthcare provider.

For each medical bill incurred, an EOB is generated by your health insurance company to explain how your benefits were applied. By the time you access your Explanation of Benefits, the health insurer would have already settled their portion with your medical provider. Any remaining balance will be billed to the patient, guardian or estate by the medical provider.

Provider discounts are a fundamental benefit of your policy

Consumers are aware that healthcare services are not only excessively high, but may appear extremely unreasonable without the benefits provided by health insurers. If it were not so, Medicare would compensate more than the “reasonable,” fractional reimbursement rate to their Medicare-assigned providers, in comparison with marketplace, group, and individual cost-share insurance rates of reimbursement. But a key benefit that insurance companies offer their customers is the discount on services, prescriptions, vision, and dental.

Your healthcare plan is a binding contract between you and your health insurance company. By joining a health plan, you receive discounts that uninsured patients do not receive. Most employer-offered insurance, individual, and marketplace plans make a distinction between in-network and out-of-network healthcare facilities and providers.

Healthcare insurance companies negotiate a contract with in-network medical facilities and providers that deliver discounts that are passed on to their insureds. The plan honors the negotiated rate for each service rendered by your in-network healthcare providers—and a lesser rate or naught, for services provided by an out-of-network provider.  In the end, how much the plan reimburses the provider depends in part, upon their network status with the insurer and the patient’s remaining deductible for out-of-pocket expenditures. After the plan pays their portion, the patient is billed by the medical provider and is responsible for the balance of the bill―hence the term “Balance Billing.” For medical services provided by an out-of-network provider, the balance bill can be excessive and shocking.

Why would an insured patient or accident victim receive a surprise billing?

Surprise billings often are a result of patients unknowingly being treated by out-of-network providers. The following list outlines the most likely events wherein a patient may receive and be obligated to pay for the balance of an out-of-network providers statement:

  1. Pre-scheduled surgeries or treatments at in-network medical facilities contracting with ancillary staff who are outside your network
    Hospitals and emergency care facilities contract with ancillary providers such as radiologists, anesthesiologists, and pathologists for staff positions. These on-staff providers may or may not be providers within your healthcare network. Anesthesiologists in particular, are often selected by the surgeon to assist your surgical team―not because they are in your healthcare network, but because they share a history of working well together. Treatment by out-of-network providers would likely result in an unexpected, sizable, surprise or balance billing.
  2. Out-of-network facility and/or care provided by out-of-network staff arising out of an ER visit.
    Emergency care and treatment—often resulting from a traumatic motorcycle accident, trucking collision or automobile crash—is logistically facilitated by the nearest trauma center without consideration of the patient’s health insurance obligations. If you were injured in an accident, your Indianapolis eastside motorcycle accident lawyer has a toolbox of strategies which, when employed, may reduce emergency expenses from out-of-network medical providers.
  3. Emergency air transport to a trauma center
    Serious accidents often occur on the backroads and highways of remote, rural areas of Indiana. Although every county in the state of Indiana has a hospital or limited treatment facility, accidents involving extreme and catastrophic injuries may necessitate advanced diagnostics and treatment options. Transportation from rural locales to major metropolitan trauma centers often require transport by air ambulance. Since 1978, emergency air-transport services have been federally regulated by the Airline Deregulation Act. It is not at all unusual for a patient air-lifted to Indianapolis to receive a bill in the amount of $25,000 – $50,000 and up.

Does Legislation Protect Insured Patients?

In 2020 and early 2021, the state of Indiana and the federal government respectively passed legislation to protect consumers from surprise billing.

The legislation passed by the Indiana General Assembly and effective July 1, 2020, has yet to address surprise bills generated from emergency room visits resulting from vehicular accidents. As an Indianapolis eastside personal injury law firm, we will eagerly watch for the Indiana Assembly to address this loophole in the current legislation.

The federal legislation entitled the “No Surprises Act” is somewhat vague in that the intent of the Act is to protect the consumer in states where balance billing policies are non-existent. Over time, the limits of the federal legislation will be tested and tried, as to how far this piece of legislation goes to protect Hoosiers who incur accident-related emergency room charges from out-of-network providers and federally regulated air ambulances.

Experienced Indianapolis Eastside Motorcycle Accident Lawyer

Ward & Ward Law Firm* is a personal injury law firm with nearly a century of combined experience in personal injury law, representing plaintiffs who have been injured through no fault of their own. Until these balance billing issues are sorted out (perhaps in the courts), contact your Indianapolis eastside motorcycle accident lawyer if you or someone you know has been injured or has died as a result of injuries received in a vehicular crash. You may also be interested in our firm’s article about the RAP Clause.

Call 317-639-9501 and ask for attorney Charlie Ward to discuss your accident claim without obligation.

*Ward & Ward Law Firm is a contingency law firm and does not get paid unless we recover for our clients. This article is not intended as legal advice. If you or someone you know has received a Surprise Billing, you should discuss it with your attorney before taking any action. Each situation is unique and only your attorney may give you legal advice.