FYI

Providing clear, accurate billing is an essential part of delivering a positive patient experience. One of the most common sources of patient confusion and grievances is balance billing, which occurs when a patient is charged more than their defined cost share for covered services.

Patient or member cost share refers to the portion of covered services that patients are responsible for paying under their benefit plan. This may include:

• Copayments: A fixed dollar amount due at the time of service or billing.
• Coinsurance: A percentage of the allowed amount for covered services.
• Deductibles: The amount a patient must pay before plan benefits begin to cover services.
  
  

Patients may also be responsible for charges related to services that are not covered under the benefit plan or for optional upgrades elected by the patient.

Follow these best practices:

• Verify eligibility and benefits prior to rendering services and determine the correct patient responsibility.
• Bill members only for the cost share amount indicated.
• Do not bill patients for denied or reduced amounts unless specifically identified as patient responsibility.

For covered services, participating providers agree to accept the plan’s allowed amount as payment in full, with the patient responsible only for their defined cost share. For DeltaCare® USA, participating providers agree to accept the member’s copayment as payment in full. Charging beyond this amount can result in a balance billing issue and a patient grievance.

Common causes of balance billing

Balance billing often occurs unintentionally due to billing misunderstandings rather than intent. Common contributors include:

1. Billing inclusive services separately
Certain services are considered inclusive (or bundled) and are already included in the procedure’s allowed amount. Billing these items separately may result in overcharging the patient. Examples may include anesthesia, routine post‑operative care, or components of a comprehensive procedure.

Best practices:

• Review coding and billing guidelines to understand bundled services.
• Ensure claims are submitted accurately to avoid inappropriate denials.
• Do not transfer financial liability to the patient for inclusive services.
  
  

2. Incorrect billing of non‑covered or upgraded services
When services are not covered by the patient’s plan or when a patient elects an upgraded option — it’s important that:

• The service is clearly identified as non‑covered or upgraded.
• The charge is billed appropriately and separately from covered services.
• The patient understands they are financially responsible for that portion.

Failure to distinguish covered versus non‑covered services can lead to confusion and disputes.

The importance of signed treatment plans

One of the most effective ways to prevent billing disputes is to obtain a signed treatment plan before services are rendered.

A signed treatment plan should:

• Clearly outline covered and non‑covered services.
• Identify estimated patient cost share.
• Confirm the patient’s agreement to proceed with treatment and associated costs.

Documenting this agreement helps ensure transparency and supports both the provider and the patient if questions arise later.

Best practices to prevent balance billing

Providers can reduce billing related grievances by incorporating these best practices into their practice:

• Verify the patient’s benefits and eligibility prior to treatment in Provider Tools.
• Ensure billing staff understand plan specific rules for participating and non-participating providers.
• Avoid charging patients for services that are included in the allowed amount.
• Clearly communicate financial responsibility before treatment begins.

These steps support accurate billing and help build trust with patients.

What to do if an overcharge is identified

Despite best efforts, billing errors can occasionally occur. When an overcharge is discovered:

• Review the patient’s plan and claim details to confirm the correct cost share.
• Issue a refund to the patient promptly for any amount paid beyond their responsibility.
• Document the correction for internal records.

Timely refunds help resolve concerns quickly and can prevent grievances from escalating.