Unethical Medical Balance Billing

Balance Billing

Balance billing is one of the most controversial topics in the modern medical industry. People often have no idea what the term even means until they become unexpected victims of the practice and learn, all to well, the hard way.

Billing the patient for an owed balance is ironically usually performed by the most profitable of all medical specialties. The majority of services provided are rendered inside respected hospitals and medical centers. These hallowed institutions seem to not only accept this horrible practice, but even encourage it, in order to keep their costs low and their facilities fully staffed.

This editorial concentrates on exposing billing practices that are used to literally extort money from people who have suffered injury, disease or other health crisis. We will define the extra billing practice, dissect the reasons why it occurs and offer warnings for patients who seek medical care, so that they might avoid becoming the next unlucky casualty.

For the record, the type of extra billing we are discussion in the essay is the variety that comes as a complete surprise to the patient. We have absolutely no problem with extra balance billing that is agreed upon by the patient prior to treatment. We only take issue with underhanded ambush billing.

What Exactly is Balance Billing?

Extra billing is defined as charging a patient the difference between the compensation paid by a health-plan or insurance policy and the amount deemed to be owed to the doctor

To simplify, we are talking about a care provider subjectively charging whatever they want for their services, the insurer paying an amount deemed fair as per industry-standards and the physician then pursuing the patient to cover the remainder of the bill.

From just this small amount of information, extra billing seems almost fair and justified. However, there is far more to this diabolical practice that makes it not only unethical, but bordering, or even surpassing, the definition of criminal in many jurisdictions.

Balance Billing for Emergency Care

Most cases of unexpected balance billing occur when a patient seeks care from a hospital emergency room. Discounting instances where a patient is admitted unconscious, alone or under true threat of death, the care-seeker will be checked-in and insurance coverage requested. 

Once the hospital agrees to accept the insurance, the patient is much relieved, since they can now forget about financial burdens and concentrate on receiving the care they require.

The patient will be treated, as per medical protocol, and eventually released. Some patients might leave with a few stitches, while others might leave with treatment toward correcting a fracture. Other patients might remain hospitalized for some time after undergoing emergency surgery, or other type of procedure, such as giving birth.

Once released, the patient begins to receive surprise bills for the care rendered. Shocked, they often contact the hospital or their insurance carrier and are told the following:

“Mr. Patient, the money you owe is not due to the hospital. They accepted your coverage as payment in full, minus your plan co-pay.  No, the bills are sent by individual doctors who took part in your care while you were in the facility.  These service providers are out of your network and are billing you directly, since your insurance only paid part of their claimed fees.”

What?  How?  Why?

This is when the confusion sets in.

Balance Billing for Planned Care

Emergency care is not the only time when extra billing becomes a big problem. Many patients know that they are facing upcoming major healthcare needs, such as a surgical intervention, radiation treatment or chemotherapy. These patients do what is expected of them and perform their due diligence to insure that all their doctors will accept their plan coverage. They go into treatment with a clean conscience, knowing that all will be paid and they can concentrate on recovery.

Once home, these patients also begin to receive bills from care providers they often do not even recognize. As in other circumstances, these patients are immediately frightened to death and reach out for help to their hospital or insurance carrier. Here is what they are told:

“Ms. Patient, Yes, all your doctors did accept your coverage, as you arranged prior to treatment. However, you failed to arrange coverage with auxiliary and accessory care providers who took part in your therapy.”

Who are these people and who hired them to become part of my care team? I do not understand.

Balance Billing is a Travesty of Medicine

When we are discussing extra billing, the amounts can range wildly.  The balance might be a few hundred dollars or it may be well over several hundred thousand dollars, depending on the services rendered and the amount of extraneous out-of-network providers who opportunistically got on-board the money-making train.

In researching this essay, I have corresponded with several dozen patients who have suffered the financial strain of balance billing after seeking medical care. Their personal monetary responsibilities ranged between $900 and $186,000. The statistical average owed was $11,400. 

Could you imagine receiving a medical bill for $186,000, completely by surprise, for care that you thought was 100% covered? 

I have also seen examples of people owing over a million dollars in extra billing charges following major traumas in out-of-network locations. This money was charged after the insurance carrier already agreed to pay industry-accepted amounts for all emergency services. 

How can this practice be tolerated, especially to such ridiculous degrees?

Worse still, if the bills are not expeditiously paid, then patients can expect to be harassed by the doctor’s billing company and collection agency.  Currently, at least 6 of the patients who took place in the interviews, prior to this article being written, are in civil court, fighting attempts to seek legal judgments by the greedy doctor. These judgments threaten liens on homes, business and bank accounts. I call this exploiting the law to justify stealing.

Balance Billing Should be a Crime

Many doctors decide not to accept any insurance coverage whatsoever.  After all, they know that health plan carriers will pay less than they could charge if they do not accept coverage. So, they simply deny all insurance coverage requests.

If this practice was confined to office settings, then the law of competition in the free marketplace would allow patients to go elsewhere for care. We have no problem with this. However, it is no coincidence that the majority of instances of extra billing occur in emergency care scenarios. 

In most of these instances, the doctor “graciously volunteers” to become a staff physician in the emergency room. They wait like opportunistic vultures for a wounded piece of prey to arrive. Then, they pounce.

Patients are typically never informed that some, or all, care providers are not working directly for the hospital. They are never warned that they could become personally financially responsible for exorbitant bills. They assume that because the hospital accepts their insurance, it would be logical that all members of the care team will also. 

This is a grave mistake. 

These are the ideal circumstances for predatory doctors to take full advantage of a patient, by providing care without any warning of the impending bills that will follow.

This practice is made worse when a specialist, like a plastic surgeon, is the first and only doctor seen in the ER. The patient is never given the choice of receiving care from an attending physician. They are merely taken as private patients, despite never seeking care from this specific provider or receiving any notice that the treatment will not be covered.

Balance Billing Ramifications

Many jurisdictions have passed legislation governing and regulating extra billing practices. However, even the most aggressive of these measures have barely curbed the flow of money from indentured patients’ bank accounts. Meanwhile, most jurisdictions allow extra billing to ruin lives, completely unchecked and unregulated.

Hospital administration seems content to allow their physicians to do whatever each practitioner wants to do, in terms of billing, as long as they show up to work and are able to care for patients on a daily basis.  Hospitals simply say, “It is not our problem”. This is where we beg to differ.

Yes, hospitals, it is your problem. We, your customers, no longer trust you. We do not believe anything you say. Your mission statements are always strikingly similar and cliché, talking about upholding the strict practices of medicine in an ethical manner. However, there is no indication of this in your actual practice. These are just lies, written in a long gone era, ignored for the sake of the almighty dollar.

Balance Billing Warnings

In order to prevent balance billing from victimizing you, or your family, it is crucial to consider the following actions from this day forward:

When seeking care, you must specify that no caregiver is to touch you, or take any part in your care, unless they accept your plan coverage. In essence, place the burden on the hospital to provide you with in-network providers for every facet of care. Some people even carry this request in writing, typically wrapped around their insurance card in their wallet.

Ask every doctor and therapist if they accept your coverage, and if not, tell them to get lost immediately.

Be wary of physicians who charge for care by simply looking into your hospital room and briefly glancing at your chart. This is not healthcare. It is stealing. Have the hospital call your own doctor to take control of your care.

Most of all, be mindful of the types of doctors with the greatest statistical tendency to commit extra billing practices. These include plastic surgeons, anesthesiologists, radiologists and all types of general surgeons. If one of these doctors happens to be the one and only physician you see at a hospital ER, ask for a resident or on-staff attending physician who accepts coverage.

Of course, these suggestions will only help in cases of patients who are conscious and not in imminent danger of death, or those who are lucky enough to be accompanied by a knowledgeable family member. 

There is no help for patients who arrive at the ER by ambulance, alone, unconscious and requiring drastic life-saving interventions. I have spoken to a few of these patients also and although every single one was glad to be alive, they all expressed the same basic opinion:

“Thanks doctor for saving my life. I just wish I knew beforehand that you were only saving me so that I could pay you off financially for the rest of my life. Thanks for nothing." (expletives removed)

I guess these people would have rather died than to live on as permanently indentured servants, paying off a physician who is already filthy rich from ill-gotten money. 

Sure, doctors have their own point of view on this topic, but they can find their own forum to express it.  It is just really hard to have sympathy for any millionaire healthcare provider who uses underhanded ways of taking advantage of people’s misfortune, when they already sit at the pinnacle of earnings potential for all professions.

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