Balance Billing Explained

When Providers Bill You Extra

Balance billing happens when a healthcare provider bills you for the difference between their charge and what insurance paid. This can result in unexpected and sometimes substantial bills.

What is Balance Billing?

Balance billing (also called "surprise billing") occurs when:

1. Provider charges $1,000
2. Insurance allows and pays $600
3. Provider bills you for the $400 "balance"

With in-network providers, this balance is typically written off. With out-of-network providers, you may be responsible.

In-Network vs. Out-of-Network

In-Network Providers

• Contracted with your insurance
• Accept allowed amounts as full payment
• Cannot balance bill for covered services
• Your cost is limited to deductible, copay, coinsurance

Out-of-Network Providers

• No contract with your insurance
• May bill full charges
• Can potentially balance bill you
• May require you to file your own claims

When Balance Billing Happens

Common scenarios:

• Emergency care at out-of-network hospital
• Out-of-network doctor at in-network facility
• Anesthesiologist, radiologist, or pathologist not in network
• Air ambulance services
• Care at out-of-network facility

The No Surprises Act

As of January 2022, federal law protects you from many surprise bills:

Protected Situations

• Emergency services (any facility)
• Non-emergency care at in-network facilities from out-of-network providers
• Air ambulance services from out-of-network providers

Your Rights Under the Law

• Pay only in-network cost-sharing amounts
• Receive a good faith estimate before scheduled care
• Dispute bills through an independent review process
• Provider and insurer negotiate the difference

Not Protected

• Ground ambulance services (for now)
• Care at out-of-network facilities you chose
• Services where you gave written consent to out-of-network care

What to Do If You're Balance Billed

1. Verify the Bill is Legitimate

   • Was this an emergency?
   • Did you have a choice of provider?
   • Is the service covered under No Surprises Act?

2. Check Your EOB

   • What did insurance actually pay?
   • Was the claim processed correctly?
   • Is the provider in-network?

3. Contact Your Insurance

   • Report potential No Surprises Act violations
   • Ask them to reprocess the claim
   • Request they negotiate with the provider

4. Contact the Provider

   • Ask about their balance billing policy
   • Request an itemized statement
   • Negotiate a lower amount if appropriate

5. File a Dispute

   • Use the federal dispute resolution process
   • Contact your state insurance department
   • Consider the independent dispute resolution process

Protecting Yourself

• Verify network status before scheduled procedures
• Ask who else will be involved in your care
• Get cost estimates in writing
• Know your rights under the No Surprises Act
• Don't sign waivers of your balance billing protections