Forum - Questions & Answers

May 22nd, 2022 - nia 4 

billing amounts

Is there a financial penalty for billing over the allowed amount?

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May 23rd, 2022 - ChrisW   238  1 

re: billing amounts

Yes, if you are submitting claims to a contracted provider, you cannot bill over the contracted amount of your fee schedule, this is called balanced billing. There is also the no-surprise rule that protects insured and non-insured or (out of network), in which civil monetary penalties can be up to $10,000. The other options are to lose your contracts with CMS or certain payers.  Keep in mind this is only if the provider knowingly violates the law, if they did not reasonably know that they violated the law, they can withdraw the bill within 30 days, and reimburses any payments received plus interest.
According to CMS, "The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers."

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