Alexis Alvarez, Esq.
Staff Attorney, Disability Rights Legal Center – Cancer Legal Resource Center
The Cancer Legal Resource Center (CLRC) is a joint program of Disability Rights Legal Center and Loyola Law School, Los Angeles. The CLRC provides information and education about cancer-related legal issues, including insurance appeals, employment rights and leave time, access to health care and government benefits, and estate planning to the public through its national telephone assistance line and its national education and outreach programs. As a staff attorney with the CLRC, I have spoken to many people whose lives have been impacted by cancer that are facing financial hardship due, in part, to unexpected medical bills they have received for services they thought were covered by their insurance. Whether the charge comes from their doctor’s office in the form of a remaining balance, the out-of-network laboratory to which their doctor sent their blood work for testing, or from the network hospital for the services provided by the out-of-network doctor on duty in the emergency room, patients are often surprised to find that they are being billed for services they thought they had already paid for. This practice is called balance billing.
Balance billing takes place when a health care provider bills a patient for the difference between the amount that the patient’s insurance chooses to pay for that service and the amount the provider chooses to charge. Fortunately, the practice of balance billing is now restricted to some degree in most states. The most common restriction states have enacted requires that contracts between health care providers and the health maintenance organizations (HMOs) they are participating in include provisions that protect members from being balance billed by a network provider for covered services. Under these provisions, network providers are prohibited from seeking compensation from a patient beyond payment of any applicable copayments, co-insurance, or deductibles for services covered by the HMO. Some states also require this type of language in contracts between providers and preferred provider organizations (PPOs). For most patients, this means that if they are receiving covered services from an in-network provider, balance billing should be a thing of the past. Sometimes, however, despite a patient’s best efforts, whether or not the individual or institution providing a particular health care service is in-network is out of the patient’s hands. Continue reading