Balance billing is a practice too many of us are forced to fight. After a doctor or hospital visit, we are sent bills for the difference between what our healthcare plan pays and what the medical provider determines are reasonable rates. The question is: Can patients be billed for this amount?

First, let's make sure we have our terms straight. Having to pay for a deductible or a co-pay does not involve balance billing. These are normal charges that you agree to pay as part of your health insurance plan.

Also, there is a difference between a balance billing dispute and a coverage dispute. If you are being billed because your healthcare insurance provider claims it does not cover the medical service or claims to only cover part of the service, your problem is with your healthcare provider and the specific contract to which you or your employer agreed.

Assuming you have a balance billing issue, you next have to distinguish between the different medical plans.

If you have Medicare or Med-Cal, you cannot be balanced billed. It is prohibited with very limited exception under state and federal law.

In California, if you have individual or group health insurance coverage (insurance regulated by the California Department of Insurance) then balance billing is prohibited for medical services rendered that are covered by your insurance plan.

For medical services that are not covered by your insurance, the medical provider may still bill you.

Lastly, there are managed health plans including HMO plans, and certain PPO plans. These plans are regulated by the Department of Managed Healthcare and often referred to here in California as Knox-Keene plans.

Balance billing most often arises under these plans because your plan provider and medical providers often have agreements that the medical provider will discount the rates. In situations where there is no agreement between the medical provider and plan provider there is often a disagreement about what is the fair rate.  At this point, you, the patient winds up in the middle getting assessed charges you never expected.

Under California law, balance billing on Knox-Keene plans is prohibited in most situations. Generally, if a medical provider is contracted with a plan provider for medical services, the medical provider cannot bill you for those covered services. A medical provider is also prohibited from attaching a lien to any judgment you may be entitled to if your medical services are covered by your plan provider

Additionally, the California Supreme Court recently in Prospect Medical Group v. Northridge Emergency Medical Group decided that medical providers cannot balance bill you for emergency services you receive. It is important to know though that emergency services are only those services you receive until you are considered stable by the medical provider.

What is still unclear is whether you can be balance billed when you receive medical services from an off-network provider covered by your plan. In this case, the plan provider determines not to pay a portion of the bill because the fee is considered unreasonable.

The California Supreme Court, did not specifically answer this question in the decision. However, if you receive medical services your plan covers from an off-network provider and your plan provider is only disputing the reasonableness of the rate charged and not whether the service is covered, there is a strong argument to indicate that you cannot be balance billed for those services.

If you receive a bill from a medical provider because he/she is disputing with your insurance provider over the reasonableness of the rate, you should dispute the bill with your medical provider and the Department of Managed Health.

Here is a sample letter you may use to dispute such charges.

If you need and help or have any questions you can always call, email, or submit an online complaint to UCAN's Fraud Squad.