Balance billing is when a health care provider charges you the difference between their full rate and what your insurance company pays. It typically happens with out-of-network providers who haven’t agreed to your insurer’s rates.
Example: a specialist charges $800 for a procedure. Your insurance’s allowed amount is $500 and they pay $400. Your insurer expects you to pay $100 in coinsurance. But the out-of-network doctor also sends you a separate bill for the remaining $300 (the “balance”). That $300 is balance billing.
The No Surprises Act (effective 2022) significantly limits balance billing in two key situations:
For non-emergency, scheduled out-of-network care, balance billing is still permitted. If you choose to see an out-of-network provider knowingly, you can be billed the full difference.
If you receive a balance bill for emergency care or for an out-of-network provider at an in-network facility, you may be protected under the No Surprises Act. Contact your insurer first, then file a complaint with your state insurance department or CMS if the bill appears to violate federal protections. Don’t ignore it — the debt can go to collections even if disputed.
Yes, if it’s for a scheduled, non-emergency service and you knowingly chose an out-of-network provider. In that case, the No Surprises Act does not apply and the provider can bill you for the full difference. Always confirm network status before non-emergency procedures to avoid unexpected charges.
.svg)