Balance Billing When You Shouldn't Be

When Balance Billing is Illegal

Balance billing - charging patients the difference between provider charges and insurance payment - is prohibited in many situations. Knowing your rights can save you thousands.

Protected Situations Under Federal Law

Emergency Services

You cannot be balance billed for emergency care, regardless of:

• Whether the hospital is in-network
• Whether the doctors are in-network
• The state where you receive care

What's covered:

• Emergency room services
• Stabilization care
• Post-stabilization care until safe to transfer

Non-Emergency Care at In-Network Facilities

When you go to an in-network hospital, you're protected from balance billing by out-of-network:

• Anesthesiologists
• Radiologists
• Pathologists
• Assistant surgeons
• Hospitalists
• Intensivists

Air Ambulance Services

Air ambulance providers cannot balance bill beyond in-network cost-sharing amounts.

Your Rights Under the No Surprises Act

You Pay Only In-Network Rates

For protected services, your cost-sharing (deductible, copay, coinsurance) is calculated at the in-network rate.

Good Faith Estimates

Before scheduled services, you can request and should receive a good faith estimate of expected charges.

Notice and Consent

Providers must give you notice of out-of-network status and get your written consent before you can be charged out-of-network rates (with limited exceptions).

When Balance Billing IS Allowed

Not Protected Situations

You may be balance billed for:

• Scheduled procedures at out-of-network facilities you chose
• Services where you signed a waiver of protections
• Ground ambulance (currently not covered by federal law)
• Care at out-of-network facilities when you had a choice

Valid Balance Bills

Balance billing is legal when:

• You knowingly chose an out-of-network provider
• You signed valid consent after receiving required notices
• The service isn't covered by federal or state protections

How to Identify Improper Balance Billing

Check the Situation

Ask yourself:

• Was this an emergency?
• Was the facility in-network?
• Did I have a choice of provider?
• Did I sign anything waiving my rights?

Review the Bill

Look for:

• Charges beyond your normal cost-sharing
• "Balance due" after insurance payment
• Amounts not reflected on your EOB
• Bills from providers you didn't choose

Compare to EOB

Your EOB should show:

• What insurance considered the allowed amount
• Your cost-sharing amount
• Any provider should accept this as payment in full (for protected services)

How to Challenge Improper Balance Bills

Step 1: Gather Documentation

• Keep the bill and all notices received
• Get your EOB from insurance
• Note dates, providers, and circumstances
• Document whether it was emergency or scheduled

Step 2: Contact Your Insurance

• Report the potential No Surprises Act violation
• Ask them to review the claim
• Request they contact the provider

Step 3: Contact the Provider

• Cite the No Surprises Act
• Explain why you believe balance billing is improper
• Request they accept insurance payment as payment in full

Step 4: File a Complaint

If not resolved:

• File with CMS (Centers for Medicare & Medicaid Services)
• Contact your state insurance commissioner
• Use the No Surprises Help Desk

Step 5: Request Dispute Resolution

The federal independent dispute resolution (IDR) process allows:

• Disputes between providers and insurers on payment
• Patients to be removed from the middle
• Binding arbitration on payment amount

State Protections

Many states have additional balance billing protections that may be stronger than federal law. Check your state's rules for:

• Ground ambulance protections
• Broader definitions of emergency
• Additional facility requirements
• Stronger consent requirements

Sample Dispute Language

"I am disputing this balance bill in the amount of $[amount]. This charge is for [emergency services/out-of-network provider at in-network facility] on [date]. Under the No Surprises Act, I am protected from balance billing for this service. Please adjust my bill to reflect only my in-network cost-sharing amount."

Know your rights and don't pay improper balance bills. The law is on your side.