Everything To Know About Direct Billing

Direct billing is a feature where medical providers bill the insurance companies directly without the policyholders having to pay for the expenses upfront. The service reduces the immediate financial burden put on the covered individual. 

In this Pacific Prime article, we will explain everything you need to know about direct billing, from what it is and how it works to its advantages and limitations. We will also include tips on how to use direct billing smoothly and how to find a suitable health insurance plan. 

What is Direct Billing?

Direct billing applies when your insurance provider has a partnership with hospitals or clinics, allowing you to “pay” for medical fees covered in your policy by presenting your insurance card. The insurance providers will cover those expenses and patients aren’t required to pay upfront.

However, each insurer has its own network of medical facilities where direct billing is accepted. For hospitals or clinics that are out of network, patients are subject to upfront payment and claim reimbursement later. 

Direct Billing VS Reimbursement Claims

Reimbursement claims differ from direct billing, also known as cashless claims, in that patients must pay upfront for all their medical expenses and file a claim with the insurance providers for reimbursement afterwards. 

Unlike reimbursement claims, direct billing saves patients from preparing relevant paperwork like medical bills, receipts, medical records, and claim forms, all of which the insurance company has to scrutinize and approve. 

The process may put a financial strain on the policyholder, as reimbursement typically takes 2–4 weeks to complete. On the other hand, direct billing hardly incurs any out-of-pocket costs aside from the agreed-upon co-payment, deductibles, and other non-covered charges as outlined in the policy.  

How Direct Billing Works

The process is simple and requires the following few steps:

Step 1: Check for Network Hospitals 

When seeking treatment, policyholders should confirm whether their chosen medical facility has a direct billing agreement with their insurer. You can accomplish this by either consulting the insurance provider for a network list or directly contacting the hospital.

Most inpatient treatments are eligible for direct billing, while outpatient services are only covered under certain plans with specified benefits.

Step 2: Present Your Insurance Card

Upon arrival, inform the staff at registration or admission that you wish to use direct billing from your insurance company. Show them your insurance card or ID, with which they will access your insurance information. 

Step 3: Receive Treatment and Claim Processing

The hospitals or clinics will provide treatment as usual. When the treatment is completed, you will need to sign a claim form but do not have to pay upfront for the covered services. The hospital will submit the bill directly to your insurance company on your behalf.

However, you may still need to pay for any uncovered costs, including deductibles or copayments, directly at the hospital. If any claims are rejected, you will be notified by the hospital or the insurer.

Simple Tips for Hassle-Free Direct Billing

To ensure a smooth billing process, follow these simple tips: 

1. Keep your account current: If you have any outstanding claims or unpaid balances with your insurance company, your direct billing may be temporarily suspended until they are settled. 
2. Confirm network hospitals before treatment: Make sure your chosen hospital partners with your insurance provider before starting your treatment procedure. This can be checked with the hospital’s website or the insurance company’s website, app, or WeChat official account.   
3. Verify your coverage: It is always beneficial to check your treatment coverage for any additional costs you may incur, like co-payments, deductibles, or other out-of-pocket costs. Clarify these potential out-of-pocket costs with the facility or your insurer beforehand. 
4. Prepare a guarantee of payment (GOP), if needed: For planned or non-emergency inpatient care, such as expensive surgery, a guarantee of payment from your insurance providers may be required to guarantee payment to the hospital. 

For further information about GOP, visit our article on Inpatient Treatment, Guarantee of Payment, and Your Health Insurance Policy. 

1. Always bring necessary documents: Always bring your insurance card and a valid form of identification (such as your passport or ID) when visiting a medical facility. The documents are important for the hospital to process your direct billing request.
2. Secure an extensive insurance plan: A well-rounded plan from reputable insurance providers can offer a wider network of medical facilities with direct billing arrangements, allowing more flexibility and convenience. 

Benefits of Direct Billing

Direct billing is a service offered by healthcare providers and insurers to streamline the payment process, benefiting patients and policyholders by allowing them to receive treatment without having to pay upfront.  

• Avoid large upfront payments: Despite being covered by insurance plans, patients don’t always have the total treatment fees at hand, especially for services at private or international hospitals where treatment costs are high. Direct billing alleviates the financial burden for the patient. 
• Seamless hospital experience: The confusing process of submitting paperwork and filing claim forms is taken off the patients as the hospitals directly settle treatment costs with the insurance companies. 

Limitations of Direct Billing Services

Direct billing offers convenience by allowing medical providers to bill your insurer directly, but it comes with several limitations to be aware of: 

• Limited hospital network: Insurers typically work with a network of medical providers that agree to offer direct billing services. If you want to receive treatment at out-of-network providers, coverage might be lower, and upfront payment will be required. 

• Pre-authorization requirements: Insurance plans may require pre-authorization for high-cost services such as MRI scans, CT scans, and surgical procedures to prove that the treatment is necessary. Without pre-approval, it is possible that your insurer may reject the claim. 

Pacific Prime Can Help 

Navigating an unfamiliar healthcare system can be complex, especially when settling in a new country. Expats, however, should be free to explore their new home without the burden of managing healthcare concerns.

Pacific Prime is a global insurance intermediary with 25 years of experience in the health insurance industry. 

Whether you prefer the convenience of direct billing or the flexibility of reimbursement claims to access hospitals and clinics of your choice, Pacific Prime can help you select and customize the right insurance plan and provide ongoing claims support.

Contact us today for impartial advice and a free plan comparison. 

Frequently Asked Questions

What documents do I need to present at the hospital?

At the hospital in China, you’ll typically need to present your passport, visa or residence permit, health insurance card, and occasionally a registration form depending on the hospital. International clinics may also ask for a copy of your insurance policy.

Will I still have to pay anything at the hospital with direct billing?

For hospitals with direct billing, you usually don’t have to pay upfront for covered services. However, you may still need to pay for uncovered items like certain medications, tests, or services not included in your insurance plan. Always confirm coverage details with your insurer and the hospital.

Is it expensive to see a doctor in China?

Seeing a doctor in China varies in cost, depending on the types of facilities and treatment. Public hospitals are affordable, usually costing ¥20–100 for basic consultations. Private and international hospitals are expensive, with fees ranging from ¥600–1200 or more per visit.

Who can help me if I have issues with direct billing?

If you have issues with direct billing, contact your insurance provider or broker immediately. You can also ask for help at the hospital’s international desk or billing office, who are typically familiar with handling foreign insurance. 

Disclaimer: Pacific Prime solely represents, operates and manages locally regulated insurance products and services in the territory of PR China. Any references to Pacific Prime Global Company or Group, the international services, insurance products or otherwise stated written or verbally, is for introduction purposes about our overseas network only as each entity is fully independent.