A key goal the Affordable Care Act is to make sure that the medical is covered by insurance plus the agreed-upon deductibles and copays. But for many families an illness or injury can still mean huge unexpected costs, because of “balance billing.”
An may have the foresight to seek treatment at an in- hospital. But if some specialists at the hospital are out– , they may bill the patient for the portion their fees the doesn’t cover – the “balance” their charges.
The practice balance billing by out– is legal in 37 states and the District Columbia, according to the Kaiser Family Foundation. The other 13 states either prohibit the practice altogether for services covered by the policyholder’s plan, or permit it only in circumstances.
The amounts demanded under balance billing can be substantial. Kaiser News reports a 52-year-old factory worker went to the ER expecting to be treated with antibiotics, and instead underwent open-heart surgery.
Although the hospital was in his , the surgeon was not. The company paid the surgeon $4,016, its rate for in- . The surgeon billed the patient for the balance his fee, which was $32,325.
The factory worker was fortunate. His hospital was in rural New York, and a new law in that state that prohibits balance billing went into effect March 31 this year, just one before he had his surgery.
The NewYork law says patients cannot be billed for more than in- charges if they have no way knowing that a provider is not in their , or if they had no choice about who provides the , such as in an emergency. The provider and insurer must negotiate a resolution the bill between themselves.
“The broad principle is people who do everything to stay in , but who get slammed with bills, are going to be held harmless,” a spokesperson for New York’s regulatory department told Kaiser News.
Dr. Kelly Kyanko, a New York University School Medicine professor of population who has studied balance billing, says New York’s new , “everyone is to see what happens, because if it works, hopefully it could be applied to other states as well.”
