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Balance Billing is the practice of charging full fees in excess of covered amounts and billing the patient for the portion of the bill that the insurance company or medical plan does not pay. In-network providers do not balance bill for covered services. They must accept the amount paid by the plan (plus any member co-payment and/or coinsurance) as stipulated in their contract. Non-network providers, however, are not under contract, so they can balance bill. See the chart for more information.
Assume PPO Plan pays:
|
Network Provider (80%) |
Non-Network Provider (60%) |
Doctor's bill for services covered by the plan |
$80* (Plan contracted rate) |
$100 |
Plan Reasonable and Customary (RandC) 1 payment |
N/A |
$80** |
Plan pays |
$64 |
$48 |
Member pays |
$16 |
Member's portion $32 Balance over RandC $20 |
Total paid by member |
$16 |
$52 |
*The plan provider accepts the contracted rate as the full amount owed for services. Member pays only the member's portion of the bill and there is no additional balance due. |
**The non-network provider does not accept the RandC amount as the full amount owed for services. The patient must pay the balance of the bill. |
