You’ve just come home from a long day at work and you’re sitting at your kitchen table, thumbing through mail when an unfamiliar bill catches your eye. It’s addressed from an emergency center you went to recently, even though you already took care of your co-pay at the time of your visit.
So then why am I receiving this bill for services?
Balance billing, the piece of mail you’ve just received, is an attempt made by the emergency facility you’ve visited to collect the remaining balance from your visit, which the insurance carrier has refused to pay. This is a direct consequence of insurance providers choosing not to honor benefits. While our partnered facilities do not balance bill their patients, and our customers, it’s still an incredibly important topic.
At Tyvan Billing, we understand the frustrations that surround billing and insurance. In fact, we’re all too familiar with these kinds of predatory insurance providers. Our business began as a response to the insurance companies that take advantage of consumers and we’re still committed to advocating on behalf of our customers. Keep reading to learn more about balance billing and why you may be denied benefits from your insurer.
Usual and Customary
Texas law requires that insurance companies pay the “usual and customary,” benefits to emergency facilities, but “usual and customary,” has never been defined. Insurance providers use this to their advantage to pay an out-of-network rate, leaving patients to settle the bulk of emergency facility costs.
Advocacy groups, like the Texas Association of Freestanding Emergency Centers, are working towards defining these terms through legislation so that insurance companies are held accountable.
The Affordable Care Act
Under the Affordable Care Act, emergency care is defined as an essential benefit. Accordingly, insurance providers must offer an in-network rate to patients for emergent visits, no matter if the facility is “in-network,” or “out-of-network.” This statute, referred to as the Prudent Layperson Standard, states that if a patient feels they are experiencing life-threatening symptoms, insurance providers must pay an in-network rate.
Now, some insurers have found ways around this law by including exemptions in their contracts. These exemptions claim the insurer may refuse to honor benefits if the visit wasn’t coded as “emergent,” which is a direct violation of the prudent layperson standard.
Collection and Mediation Process
The collection and mediation process is further complicated by patient involvement.
Since there’s no accountability for huge institutions, like insurers, it’s often left to the patient to advocate for and fight to receive benefits. We work diligently to ensure this is never the case for our customers, but until legislation is put in place to standardize this process and hold insurers accountable, they may continue to dismiss your legitimate claims to benefits.
Our goal is to empower our customers through education and advocacy. We’ll work tirelessly to ensure you’re receiving the benefits you deserve from your insurance provider.
Still have questions? Visit our FAQ page or speak with one of our team members at (713) 357 – 2535 to address any of your concerns.