What Is Balance Billing?
You may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible when seeing a doctor. You may have to pay additional costs or owe the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” providers and facilities have not signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the amount charged for a service. This is known as balance or “surprise” billing. See our “Surprise Billing Notice” form for more information.
Balance billing can happen when you can’t control who is involved in your care, like when you have an emergency or unexpectedly receive treatment from an out-of-network provider.
When Are You Protected From Balance Billing?
You have protection against balance billing in several situations, such as:
- Emergency Services: The most an out-of-network provider can bill you is your plan’s in-network cost-sharing amount (copayments, coinsurance, & deductibles), including services you may get after you’re in stable condition unless you give written consent & give up your protections not to be balanced billed
- Certain services at an in-network hospital or ambulatory surgical center: When you get services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent & give up your protections
You’re never required to give up your protection from balance billing, and you don’t need to get out-of-network care. You’re only responsible for paying your share of any cost (copayments, coinsurance, and the deductible you would pay to a provider or an in-network facility). Your health plan will directly pay any additional costs to out-of-network providers and facilities.
Your health plan must:
- Cover emergency services without requiring you to get approval for services in advance
- Cover emergency services by out-of-network providers
- Base what you owe the provider or facility on what it would pay the in-network provider or facility & show an explanation of your benefits
- Apply any amount you pay for emergency services or out-of-network services towards your in-network deductible & out-of-pocket limit
Good Faith Estimate
You have a right to receive a Good Faith Estimate of expected charges at any facility. Under the law, health care providers need to give patients who don’t have insurance or are not using insurance an estimate of the bill for medical items and services.
The details of a Good Faith Estimate are as follows:
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, & hospital fees
- Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item—you can ask your health care provider & any other provider you choose for a Good Faith Estimate before you schedule an item or service
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill
- Make sure to save a copy of your Good Faith Estimate
- 2060 Charlie Hall Blvd #301
- Charleston, SC 29414
- Phone: 843-571-4800
- Fax: 843-763-7621
- Monday: 8:00 AM – 4:30 PM
- Tuesday: 8:00 AM – 4:30 PM
- Wednesday: 8:00 AM – 4:30 PM
- Thursday: 8:00 AM – 4:30 PM
- Friday: 8:00 AM – 12:00 PM
- Saturday: Closed
- Sunday: Closed
We are a proud partner of US Eye, a leading group of patient-centric, vertically integrated multi-specialty physician practices providing patients with care in ophthalmology, optometry, dermatology, audiology, and cosmetic facial surgery.