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Balanced Billing: Rarely a Good Deal for Healthcare Consumers


If you were injured in a car accident, what happens after the injury is sometimes even more painful than the accident itself.

When health insurance doesn’t cover the whole bill for your accident-related medical care, doctors and hospitals often try to recoup their losses by going after the injured party — you. This practice is known as balanced billing.

What is Balanced Billing?

Balanced billing is an attempt by a medical care provider to collect the balance between the full (retail) charge for a medical service and the negotiated discount rate paid by the insurance company. Balanced billing occurs when providers bill the patient for charges — other than co-payments, coinsurance, or deductibles — that exceed the health plan’s reimbursement for a covered service. Although network providers are contractually prohibited from balanced billing, the practice is common among non-network providers.

Balanced Billing and Personal Injury Lawsuits

If you are awarded a financial settlement from an auto insurance company in a personal injury lawsuit, you may be forced to use that money to pay the difference between what your medical care cost and the amount your health insurance company reimbursed the provider for treatment. While not everyone receives an injury settlement, many doctors and hospitals argue that they have the right to collect what isn’t paid by heavily discounted rates contracted with private insurance companies and government payers like Medicare and Medicaid.

Is Balanced Billing Legal in Colorado?

Colorado law prohibits balanced billing in circumstances where an insured gets treatment from a participating, or in-network, provider, and an unscrupulous doctor or medical facility bills the insured for services it previously billed to the insurance carrier. The state’s laws also protect insured patients from getting stuck with retail charges if they inadvertently use an out-of-network provider, or have no choice, such as if they’re injured in an accident and there’s no network provider available in the area.

In the case of personal injury lawsuits, medical care providers sometimes choose to ignore Colorado’s restriction against balanced billing and attempt to collect for services already paid for by the insured’s insurance company, at times even by sending bills to the personal injury attorney handling the claim in an effort to recover the balance.

Possible Exceptions

Balanced billing may be allowed in Colorado in limited situations where the insured received medical care from an nonparticipating or out-of-network provider, although Colorado law requires that 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.

Services must be provided in a timely manner also. According to Colorado law, a provider network must be “sufficient in numbers and types of providers to assure that all covered benefits will be accessible without unreasonable delay.”

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My daughter and I first consulted with Dan Rosen after a very serious auto accident. Dan had several phone conferences with me, and Tracie was available whenever I called. We would recommend personal injury attorney Dan Rosen to anyone!
Sally from Denver, Colorado

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