Insurance terms that may be very familiar to those of us in the industry can be a mystery to the general public. Working with a client to explain the technical details of their plan is well worth the investment of your time to avoid unpleasant surprises when invoices arrive. With that goal in mind, let’s break down the practice of balance billing.
There are many good reasons for Quartz members to get health care services from in-network doctors, including reduced costs through our persistent provider negotiations. When they are seen by out-of-network doctors, these charges may not be reduced through negotiations in any way, and the difference may become the patient’s responsibility. This is called “balance billing” and here’s how it works.
When a doctor participates in the Quartz network, he or she agrees to charge patients a specific rate for services (the “Allowed Amount”). The Allowed Amount is the basis for Quartz’s benefit payment and the member’s cost-sharing payment.
When someone gets care from an out-of-network provider and that provider charges more than the Allowed Amount, Quartz will compare charges from other doctors in the area for the same service to decide what is a usual, customary and reasonable (UCR) charge. Quartz will pay the doctor at the UCR rate.
If there is still a difference between cost of the service and the amount paid by Quartz, the provider may bill the patient for the difference. This is known as balance billing. These charges do not apply to the plan’s maximum out-of-pocket costs.
To avoid balance billing, patients should try to see doctors who are in their plan’s provider network. QuartzBenefits.com/findadoctor is a handy resource for finding network providers.
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Quartz Health Solutions, Inc., Unity Health Plans Insurance Corporation, Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota, Physicians Plus Insurance Corporation, Gundersen Health System, UnityPoint Health and UW Health are separate legal entities. Plans are underwritten by Unity Health Plans Insurance Corporation unless otherwise noted.