Beyond a routine annual check-up and an apple a day in hopes of keeping the doctor away, individuals enrolled in private health benefit plans generally are not keen to see the inside of a hospital or emergency department. However, when emergency or more extensive treatment is necessary, so long as the patient goes to his health insurance carrier’s in-network providers, and so long as premiums, deductibles and co-insurance are paid, covered persons expect that their carrier will pay for the cost of their medically necessary care. Unfortunately, in many states, including Pennsylvania, even if a covered individual receives treatment in an in-network hospital or emergency department (often for emergent reasons beyond their control), there is often a terrible surprise awaiting them when the bills start to arrive. In many cases after the ordeal, patients learn they were treated by an out-of-network provider when they receive an unexpected “balance bill” from that provider. This scenario is becoming more frequent in light of increasing complexity in how health care facilities contract with providers and how health insurance carriers develop their networks. These surprise charges contribute to the rising costs of health care, and covered persons find themselves with little to no recourse. With no federal laws explicitly prohibiting this practice, a number of states are stepping up to enact “surprise balance billing” laws that protect health care consumers and ensure they receive the information necessary to make informed decisions about their health care.

An in-network provider is a physician, hospital or other health care provider with whom a health plan has a negotiated reimbursement rate for covered medical services. “Balance billing” refers to an out-of-network provider’s practice of charging covered persons for the difference between their fees for medical services, which are not negotiated with the carrier, and the carrier’s allowed fee amount under the terms of the plan. Balance billing typically occurs in two settings. First, where a covered person chooses to see an out-of-network provider and their plan provides coverage for such services, they are responsible for that provider’s billed charges beyond what the plan agrees to pay. For example, where a plan provides coverage for out-of-network care with a 60 percent coinsurance obligation, the covered person is responsible for 60 percent of the provider’s billed charges. The plan will pay the remaining 40 percent of the covered services. In these instances, the covered person is aware that they have gone outside the plan’s contracted network of providers and is making an informed decision about their care and knowingly taking on the responsibility of the balance bill.