Improper ‘Balance Billing’: Examples of a Rising Trend

For patients seeking care from an out-of-network doctor, costs can increase dramatically – and, in some cases, illegally.
Image source: Wikimedia Commons

In yesterday’s post, we introduced an emerging concept known as “balance billing,” which results in skyrocketing medical expenses and increased medical debt for unsuspecting patients. As a brief review, balance billing occurs when a patient seeks treatment from an out-of-network doctor, who then bills the patient for the maximum allowable charges – which are often much higher than the maximum allowable charges for the same treatment in-network. Moreover, doctors are inviting other out-of-network doctors to participate in patient care without the patient’s knowledge or consent, as we will illustrate in today’s post.

The following illustrates several real-world examples of balance billing and how the process can create significant financial hardship for unsuspecting patients. Moreover, balance billing fraud schemes can lead to liability and even criminal charges for the provider, which we will outline in today’s post as well.

The New York Times profiles a balance billing victim

In a recent article[1. http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html?_r=0] published by The New York Times, a 37-year old orthopedic patient detailed his long road to financial recovery following an unexpected balance billing experience. According to the details of the article, the patient dutifully researched the total costs to expect once he opted to seek treatment for a herniated disk from an out-of-network provider in New York City. Specifically, the patient awaited a $56,000 bill from Lenox Hill, a $4,300 bill from the anesthesiologist, and a $133,000 bill from the orthopedic surgeon, who had already agreed to accept a fraction of that fee.

What he didn’t anticipate, however, was a supplemental bill for $117,000 from an unknown, out-of-network second orthopedic surgeon – someone with whom he had never made acquaintance or even discussed his condition. In this case – which is becoming increasingly common – the specialist became involved in the surgery once the patient was unable to consent to the added costs, and the patient was left to pay the hefty bill in the end.

Other balance billing examples

Balance billing can also occur at a time when a patient feels most vulnerable: the emergency room. When a patient enters the local, in-network emergency department, he or she likely feels reasonably certain that the doctors and nurses providing care are also in-network. However, it is not uncommon for hospitals to allow out-of-network providers to treat patients without the patient’s knowledge – at least, until the final bill arrives. In these cases, hospitals are using contractors to provide emergency services and patients are not realizing the differential until certain medical services are either not covered or only partially covered.

Another area causing concern involves the use of out-of-network anesthesiologists for an otherwise covered medical procedure. In these cases, patients have no reason to believe their anesthesiologist would be out-of-network until a $5,000-$10,000 bill arrives, which the insurance provider has refused to pay.

Contact Berger Montague today

If you are receiving suspicious charges on your medical bills, please do not hesitate to contact Berger Montague for a thorough review of your situation.