Emerging Fraud Trends: The Rise of Balance Billing

Calculating medical bills can be very difficult in the face of balance billing, which is becoming a major problem for patients.
Image source: Wikimedia Commons

At Berger Montague, we strive to keep on top of the latest emerging trends in the fraud landscape, particularly when the misconduct drives up the costs of healthcare for policyholders and taxpayers alike. Over the next two posts, we will examine an emerging fraud trend known as “balance billing,” which our firm has tackled head-on and will fight against on behalf of our courageous clients and whistleblowers.

In today’s post, we will introduce and explain the concept of balance billing from a false claims perspective, followed by an examination in tomorrow’s post of several balance billing examples from real-world patients faced with unbelievable – and unexpected – healthcare costs. As always, if the concept of balance billing starts to sound a little too familiar given your recent healthcare costs, do not hesitate to contact our office as soon as possible to review your options.

Balance billing – What is it?

Balance billing[1. http://www.forbes.com/sites/christinalamontagne/2015/01/26/what-is-balance-billing/2/] is also known by a more accurate nickname: extra billing. It is also referred to colloquially as “drive-by doctoring,” and refers to the inclusion or intervention of out-of-network specialists during a patient procedure that were not mentioned or disclosed prior to the patient agreeing to the scope of treatment. To better understand the balance billing process, it helps to review the procedural mechanisms set in place by insurance companies and how doctors and physicians have manipulated these regulations to leave patients with hefty out-of-pocket bills in the weeks following surgery.

Billing patients for extra charges

Balance billing occurs primarily when patients opt to seek medical treatment from an out-of-network provider or a provider not enrolled with a policyholder’s insurance policy. Of course, patients in need of specialized care are free to seek treatment from an out-of-state physician, but the insurance company will only pay a small portion of the total bill owed. Accordingly, patients pursuing this course will budget for the anticipated difference, which is often much higher than originally calculated.

When a doctor is “in-network,” he or she has already entered into a contractual agreement with the insurer to provide services at an agreed-upon rate. This rate often shows up on an Explanation of Benefits (EOB) as the amount “billable to the insured” – and is usually much lower than the total rate listed by the provider. However, when a patient seeks treatment and is “out-of-network,” the doctor is under no contractual duty to provider reduced-cost services whatsoever and can bill the patient for the maximum amount possible.[2. http://kff.org/private-insurance/state-indicator/state-restriction-against-providers-balance-billing-managed-care-enrollees/]

In addition, doctors are now beginning to include other specialists in the treatment of out-of-network patients, often without the patient’s consent or knowledge. This practice, which is becoming an emerging trend on the false claims forefront, has resulted in an influx of medical debt for patients – some of which may be the result of unfair and intentional misconduct.

Contact Berger Montague for more information today

If you believe your provider may be engaging in a balance billing practice and would like to discuss your options with a reputable attorney, please do not hesitate to contact Berger Montague today!