Skip to content

What Providers Need to Know Before They Balance Bill


By: Karina Gonzalez

Balance billing occurs when a provider collects from a patient the difference between the amount billed for a covered service and the amount  paid for that service.  Balance billing does not apply when collecting deductibles, copayments or coinsurance.

Under Florida law, a provider may not balance bill a patient for any service, if an HMO is liable and responsible for payment.  Contrary to what many people believe, this is true whether you are in-network or out-of-network.  Even hospital based out-of-network physicians, such as anesthesiologists, pathologists, radiologists or emergency room physicians cannot balance bill HMO members where the hospital has a contract with the HMO or there was authorization given for an episode of care.

Under Medicare managed care, any Medicare participating provider (as a condition of its participating provider status) must accept payment from a Medicare Advantage plan as payment in full, even though the provider may be nonparticipating.

Medicare prohibits the provider from balance billing Qualified Medicare Beneficiaries for Medicare cost-sharing (which includes deductibles, coinsurance and co-payments) for Part A or Part B cost sharing.  Medicare payments or Medicaid payments are considered payment in full to the provider for services given to a Qualified Medicare Beneficiary.  A Qualified Medicare Beneficiary is someone whose income does not exceed 100% of the Federal Poverty and who is eligible for Medicaid paying Medicare premiums, deductibles and coinsurance, also known as dual eligibles.

Out-of-network providers can balance bill patients who are covered under a self-funded employer plan. These types of plans are self funded by the employer or a union and employer or union assumes financial risk for providing healthcare benefits to its employees. In Florida, there isn’t a mandatory requirement that a provider submits a balance bill, but there is no prohibition either. Balance billing is also permitted for nonparticipating PPO providers and for participating providers whose contract permits it.

The key aspect to consider in whether to balance bill is knowing who the payor is and the sort of service provided.

Karina will be presenting a FREE webinar for providers on September 24th from 12-1pm EST. “Payor Issues: Getting Paid, Staying Paid, and Defending It” registration is now open. Click HERE to reserve your spot!