Submitted by Rachel R on Mon, 10/19/2015 - 10:55am
Don't pay balance-billing you may not owe under North Carolina law
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There’s nothing worse than checking to make sure that your medical provider is in-network only to be slapped with a balance due notice saying your insurance didn’t cover all of the services because there was an out-of-network issue. This is known as “balance billing” or “surprise billing” and, in some cases, the type of North Carolina medical insurance policy you have may block this nasty practice. Here’s a look at how this medical billing happens and why you may not have to pay.
What is “balance billing” or “surprise billing”?
If you go to an out-of-network insurance provider, you can expect that some (or all) of the service may not be paid. If you have an HMO, there are usually no out-of-network benefits except in the case of an emergency when you cannot get to a network provider or facility. With POS, PPO or other flexible policies, you can usually go out-of-network, but may be charged a coinsurance amount (a percentage of the amount billed) and may also be subject to a deductible.
However, you know this going into it because you’ve made the choice to go with an out-of-network provider. Surprise or balance billing is different, though, because it occurs when you think you are having an in-network procedure done but then are hit by unexpected charges. You can check and make sure the surgical center or doctor’s office is in-network and the surgeon as well. But then, for example, you’ll get a bill because the anesthesiologist was out-of-network.
It seems ridiculous (and impossible) that you should have to prearrange that every person who steps into your procedure is in-network when you’ve done your groundwork with the facility and surgeon. But this is exactly what happens. In this example, if you’re in an HMO, which means no out-of-network privileges, you could get a major bill for the anesthesiology services. That doesn’t seem fair and, in some cases in North Carolina, you absolutely do NOT have to pay this bill.
What’s the North Carolina law on balance billing?
Many states, like New York, have very aggressive anti-balance billing statutes. North Carolina does not have a terribly hard-hitting law, but it can help in some cases. In North Carolina, members of HMOs cannot be charged for balance billing. However, those with PPO coverage may be balance billed. The NC law reads:
For purposes of health care plans provided by a Health Maintenance Organization, if a limited provider network or delegated entity provides or arranges to provide services to enrollees through a facility-based physician or provider who is not a member of the HMO delivery network, on payment by the HMO of the usual and customary rate as defined under the health care plan or an agreed rate for health care services, the enrollee is not liable for any further payments to the facility-based physician or provider except for payment of any applicable co-payments, coinsurance, or deductibles for the covered services.
If your coverage is with an HMO and you get a balance bill, you’ll have to fight it, but you should be able to get the excess charges dropped. First, contact your insurance company to find out the process for appeal, then you’ll likely also have to contact the care provider’s billing service. If you get no satisfaction from either, contact the North Carolina Department of Insurance.
How to deal with medical bills you can’t pay
If you suffered a medical crisis for which you did not have adequate insurance coverage, you may have tens of thousands of dollars of medical bills piled up. Medical bills are unsecured debts and can be totally discharged in Chapter 7 bankruptcy to give you a clean financial slate. Credit card balances are also unsecured debts and can be fully discharged in bankruptcy as well. To find out more about getting free of excessive credit card and medical debt, contact the Law Offices of John T. Orcutt today. Call +1-919-646-2654 for a free consultation at one of our offices in Raleigh, Durham, Fayetteville, Wilson, Greensboro, Garner or Wilmington. Get the peace of mind you need.
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