By: Philip R. Frankfort

The Illinois Balance Billing Law (Public Act 96-1523) became effective on June 1, 2011. “Balance billing” typically happens when you are treated by an out-of-network physician who does not accept as payment in full the reimbursement that he or she receives from your insurance company. Thus, after receiving payment from your insurance company, the out-of-network physician sends you a bill for the balance. It can be a nasty surprise.

When you use in-network physicians, you would normally never owe any payment beyond the applicable co-pays and deductibles. Sometimes, despite your best efforts, you end up using an out-of-network physician without even being aware of it. For example, you may select an in-network hospital, and an in-network surgeon for a necessary operation, only to find that the anesthesiologist (for example) is out of network. You would only know this after you receive a bill from the anesthesiologist for a balance owing over and above the insurance company payment.

PA96-1523 brings some relief to consumers who have selected an in‑network hospital or ambulatory surgery center. The Act provides that an out-of-network “facility-based provider” is prohibited from billing a patient other than what the deductible/co-pay would have been if the physician was in-network. Essentially, the out-of-network “facility-based provider” must accept whatever fee he or she can negotiate with the insurance company, and you (the patient) are not involved. If they fail to negotiate an acceptable fee, the statute provides for a binding arbitration process to resolve the matter. We understand, from anecdotal reports, that in virtually every instance where the Act would be applicable, a fee is agreed-upon prior to binding arbitration.

Who is a “facility-based provider”?

Under the Act, the following specialists fall within the definition: radiologists, anesthesiologists, pathologists, neonatologists, and emergency physicians. To be eligible for the Act’s protections, the patient must have selected an in-network hospital or ASC, and must not have knowingly selected the out-of-network physician. If you receive a “balance bill” from a “facility based provider” in circumstances that you feel are covered by the Act, we suggest the first thing you should do is call your insurance company, and see if they will intervene on your behalf. If not, contact the physician and remind him or her about the Act.