Balance Billing

Balance billing is when a provider bills you for the difference between what they charged and what your plan allowed. If the hospital billed $6,000, the plan allowed $2,000 and paid $1,600, an out-of-network provider might send you a bill for the remaining $4,400 — the "balance." In-network providers can't do this because their contract prohibits it.

The classic scenario: you go to an in-network hospital for surgery, but the anesthesiologist or radiologist working that day is out-of-network. You had no way to know, no way to choose, and now you're staring at a $3,200 balance bill. The federal No Surprises Act (effective 2022) banned this in most emergency and ancillary situations — emergency care, air ambulance, and out-of-network providers at in-network facilities are protected. But it did not eliminate balance billing everywhere: scheduled out-of-network care, ground ambulance in most states, and standalone out-of-network facilities can still balance bill.

The takeaway: if you receive a balance bill after emergency or in-network facility care, don't pay it. File a No Surprises Act complaint at cms.gov/nosurprises and dispute the bill in writing. The provider is often required to accept the qualifying payment amount as payment in full.