I first wrote about “Balance Billing” four years ago. I will revisit balance billing here, but first I want to discuss the new “No Surprise Act” (NSA) and its impact on private practice. The intention of the law is to prevent individuals from being surprised by unexpected medical bills. It primarily applies to the medical profession. Counselors are like the porpoise in the tuna net! “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.” Becky Beaton-York, PhD.

However as of this writing NSA does not apply to clients who are using their insurance. NSA applies to self-pay and clients who have insurance but do not want to use it. By now you should have your “Good Faith Estimate” and your “Notice of The No Surprise Act” to display in your office and/or website.  I would suggest that you include the following in addition to clinical services and costs in your Good Faith Estimate:

Charges for review of records, extensive phone consultation or correspondence, travel time, legal fees, and time for responding to subpoenas or court orders, depositions, etc. These services provided for the client will be billed at the hourly rate of 90837  Psychotherapy >53 minutes and you may be required to pay a retainer before these services are rendered.

This Good Faith Estimate lists rate for each service provided. We will work with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.
*In office and telehealth services have the same fees.*

I have received this Good Faith Estimate ______Client Signature_______ __Date_______ 

Moreover, under NSA, if a client sees another clinician in your practice (for a specialty area, an emergency session, maternity leave or transfer etc.,) and the fee is higher than the treating counselor,  the client can should only be billed what was the fee in the good faith estimate or a new Good Faith Estimate needs to be given to the client.

Now back to “balance billing.” I still hear confusion from counselors so I want to revisit it again in my column. According to healthcare.gov, “balance billing occurs when providers bill a patient for the difference between the amount they charge and the amount that the patient’s insurance pays”. Sometimes it’s legal and sometimes it isn’t.

It is not legal to bill a client the difference between what you charge and the negotiated fee when the counselor has contracted with the client’s insurance company (in-network). For example, if your fee is $160.00 and your contract (in-network) with ABC insurance company and the contracted  fee is $95.00, with a co-pay of $15.00, you agree to accept $80.00 from ABC insurance (co-pay + insurance payment = $95.00). You must waive the remaining $65.00 of your $160.00 fee. If you bill the client for that remaining $65.00 that’s called balance billing and it is not legal. You cannot deduct the $65.00 from your taxes because the IRS doesn’t value your time.

It is not illegal to bill the client the total $160.00 if you are not contracted with ABC insurance. Moreover, the client may have “out-of-network” benefits. This is where the insurance may reimburse the client for a percentage of what’s called usual and customary fees. These U&C fees are more times than not, lower than your fee. The balance bill is the difference between what the insurance pays and your total fee and it is legal to charge the client for the remainder. In fact, I recommend if you do not have a contract with the client’s insurance company collecting your full fee at the time of service. The insurance can reimburse the client of any out of network benefits.

This can be confusing to clients, so it is imperative to inform your clients using insurance of your fees and how they are paid. This needs to be stated in your informed consent document and discussed with them, so they fully understand their financial obligation.

For NSA you cannot embed a Good Faith Estimate in your informed consent. The Act states it must be a separate form.  Welcome to more paperwork!!

For more information, consult your legal advisor. As I tell my lawyer friends, if you don’t practice counseling, I won’t practice law.