According to CMS, who decides if balance billing is permitted in a PFFS plan?

In a Private Fee-for-Service (PFFS) plan, the determination of whether balance billing is permitted is made by the PFFS plan itself. This means that the rules regarding balance billing are established by the plan's policies and guidelines. The PFFS plan outlines the conditions under which providers may bill members for the difference between what Medicare pays and what the provider's charges are.

Balance billing occurs when the provider charges the patient the difference between the billed amount and the amount reimbursed by the insurance plan. In a PFFS context, it is crucial to understand that each plan may have different regulations and provisions concerning cost-sharing and billing practices. Therefore, the specific plan the member is enrolled in has the authority to dictate these billing practices.

While other options might reflect certain parties' interests or involvement in the billing process, they do not have the authority to set policy on balance billing like the PFFS plan does. For instance, while providers may have input and may restate their charges, it ultimately falls on the PFFS plan to establish whether or not balance billing is allowed in their network. Additionally, members themselves or government agencies do not have the autonomy to change or dictate these billing practices as they are governed by the PFF