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  • March 20, 2012

IS BALANCE BILLING LEGAL IN COLORADO?

IS BALANCE BILLING LEGAL IN COLORADO?

150 150 Gregory A. Hall

WHAT IS BALANCE BILLING

Balance billing occurs when a medical care provider bills an insured the difference between the provider’s full charge for a service and the amount it agreed to accept from the insurance company as payment if full for that service – the negotiated rate. So it’s an attempt by the medical care provider to collect the balance between the full charge for a service and the negotiated rate paid by the insurance company to the provider for that service. The balance billed has nothing to do with co-pays made by the insured.

Colorado law prohibits balance billing in situations where an insured obtains treatment from a participating provider. C.R.S. § 10-16-705(3). The prohibition against balance billing applies to services provided by a participating provider (sometimes called an in-network provider). Illegal balance billing occurs when an unscrupulous hospital or doctor, that is a participating provider, bills the insured for any service it previously billed to the insurance carrier.

So for example, an insured, while in the hospital, is given an aspirin. Without insurance, the hospital charges the patient $5.00 for the aspirin, but the hospital has agreed to accept $1.00 from the insurance company as payment in full for the aspirin. Illegal balance billing occurs when the person who has insurance is hospitalized at a participating hospital but then gets a bill for $4.00 for the aspirin, which is the difference between the full retail charge for the aspirin ($5.00) and the amount the hospital agreed to accept from the insurance company as payment in full for the aspirin ($1.00). So otherwise stated, prohibited balance billing occurs when an insured is hospitalized, then gets a bill from the hospital for services covered by the person’s health insurance plan. It is illegal because even though the hospital agreed to accept the amount paid by the insurance company as payment in full for the service, it turns around and bills the insured for the difference between the retail price and the negotiated rate. If a person obtains treatment from a participating provider, then Colorado law requires the health insurance carrier to shield the insured from having to pay any amount above what the insurance company paid to the participating provider.

Often times, especially when there is a settlement or verdict obtained by the insured on a personal injury lawsuit, medical care providers patently ignore Colorado’s prohibition against balance billing and attempt to collect for services already paid for by the insured’s insurance company. Unscrupulous medical care providers have even been known to send misleading bills to the personal injury lawyer handling the claim for the insured in attempt to recover the balance billed.

WHEN IT’S LEGAL FOR A PROVIDER TO BALANCE BILL

Balance billing may be allowed in situations where the insured seeks services out of network with a medical care provider that does not have a contract with the insurance carrier – such a medical care provider is called a “nonparticipating provider” under Colorado personal injury law. Colo. Rev. Stat. § 10-16-704 provides a scheme for the payment of benefits to an insured under managed health care. The benefit level an insured receives under C.R.S. § 10-16-704 depends on whether there is an adequate network available to the insured and whether the insured receives services from a participating provider or a nonparticipating provider. The statute requires a health insurance carrier, providing a managed care plan, to maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay. Colo. Rev. Stat. § 10-16-704(1).

If there is a participating provider within a reasonable distance from the insured’s geographic area, and the insured knowingly seeks services from a nonparticipating provider, the insurance carrier is only obligated to pay: (i) the lesser of the provider’s bill of charges, (ii) a negotiated rate, or (iii) the greater of the health maintenance organization’s average in-network rate for the relevant geographic area or the usual, customary, and reasonable rate for such geographic area. Colo. Rev. Stat. § 10-16-704(2)(i)(I). If the reimbursement rate described above is not equal to the nonparticipating provider’s bill of charges, the nonparticipating provider may balance bill the insured. Colo. Rev. Stat. § 10-16-704(2)(k).

In sum, if an insured seeks treatment with an out-of-network provider (a nonparticipating provider), then the law does not prohibit that medical care provider to balance bill the insured. Colo. Rev. Stat. § 10-16-704(3) mandates that an insurer pay to an insured only in-network benefits for all services performed at an in-network facility.

YOUR HEALTH INSURANCE COMPANY IS REQUIRED TO MAINTAIN AN ADEQUATE NETWORK

When a network is inadequate because there are no participating providers available, the insurer must ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit is obtained from participating providers. Colo. Rev. Stat. § 10-16-704(2)(a). An in-network facility is adequate where there are participating and nonparticipating providers: A carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all covered benefits to covered persons will be accessible without unreasonable delay.   In the case of emergency services, covered persons shall have access to health care services twenty-four hours per day, seven days per week.   Sufficiency shall be determined in accordance with the requirements of this section and may be established by reference to any reasonable criteria used by the carrier․ C.R.S. §10-16-704(1).

Moreover, in any case where the carrier has no participating providers to provide a covered benefit, the carrier shall arrange for a referral to a provider with the necessary expertise and ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were obtained from participating providers․ C.R.S. §10-16-704 (2)(a).

When a covered person receives services or treatment in accordance with plan provisions at a network facility, the benefit level for all covered services and treatment received through the facility shall be the in-network benefit. C.R.S. §10-16-704 (3).

Colorado personal injury law can be complicated. If you’ve been seriously injured by another’s negligence or intentional conduct, you should contact Denver Personal Injury Lawyer Gregory A. Hall. If you retain him, Mr. Hall can help ensure that you’re not illegally balance billed by your doctor or hospital and that the at-fault party pays you a fair amount to compensate you for your personal injuries.

Gregory A. Hall
Law Office of Gregory A. Hall
3570 E. 12th Avenue, Suite 200
Denver, CO 80206
Ph. 303-320-0584
Email: gregory@federallaw.com
Web: www.adenverlawyer.com

4 comments
  • Connie Levine September 2, 2014 at 4:06 pm

    You refer to CRS 10-16-704–all covered services and treatment received through the network facility shall the in-network benefit.

    Wasn’t that repealed in 2010 so it no longer applies?

  • Mark Halladay December 23, 2015 at 12:26 pm

    In an emergency sitituation that required hospitalization, I went to an out-of-network facility ( closet facility) and ended up getting balance billed for the greater portion of a $240,000 bill from the facility. Do I have a legal recourse? I realize that both ACA and Colorado allow balance billing but…. There was an opportunity to move me to an in- network- facility, after a period of recuperation, but it was decided to not be prudent.

  • Rick Hendricks May 12, 2016 at 1:15 pm

    Hello Mr. Hall,
    Thank you for publishing this information. I was researching a situation that neither of these two scenario quite address. My wife had orthopedic surgery with an in network surgeon, at an in network hospital. Prior to surgery we had been assured that everything was in network by the surgeons office. We paid our co pays and deductibles. The surgical team brought in an assistant surgeon without our knowledge. He is out of network and we are receiving a bill from his office, and they are threatening collections. I don’t feel that we are required to pay this. This led me to your site. Any thoughts would be appreciated. Thank you

  • Guri Singh, MD July 1, 2016 at 4:31 pm

    Thank you, Mr. Hall, for that comprehensive review of the issue of ‘balance billing’.
    Two situations that baffle me as a solo PCP:
    1. If a Medicaid patient gets services that Medicaid won’t cover, AND if the patient has signed the ABN papers, what is illegal about the physician billing ‘uncovered’ services, as long as they are deemed medically necessary?

    In other words, if ‘balance billing’ is allowed for ‘out-of-network’ PROVIDERS, why is it illegal for ‘out-of-coverage’ services? Again, I am not talking about services that fall an inch outside the evidence-based guidelines from the ADA, the AHA, the ACC, the CDC, etc..
    But here’s someone with documented deficiency of Vitamin B12. The recommended treatment involves monthly administration – usually done during a visit for multiple other comorbidities.
    The insurance does not cover this service because it is considered easy enough for the patient to do it at home by themselves, “as long as they get adequate training from the provider”
    Most patients in this predicament make one of three choices:
    1. Learn and ‘shoot’ yourself at home – this excludes most seniors over 70, for a variety of obvious reasons. And the are the folk who are already spending a lot more than they get from the old-age-benefits. They have problems with vision, hearing, cognition – in different degrees and combinations.
    2. Buy some OTC B12 and take the pills… some folk get enough from that to take care of the problem.
    3. Ask the doctor to give you the shot and you’ll pay him the whopping $8 for it!

    ‘Balance Billing’ or ‘Uncovered-but-necessary-tx-billing’?

    Gets murky in many such ridiculously simple-looking equations.

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