Jennifer Albach RN, CCM, LNCC
Balance billing occurs when providers or facilities bill you for the difference between the amount your health plan pays them and the amount the provider or facility believes to be adequate reimbursement.  Sometimes, providers will try to get a second slice of the pie by billing the patient not only for the portion he owes after the insurer has paid its part, but also the difference between the charge contracted with the insurer and its regular charge.  For example, a specialist charges $ 100.00 for an office visit.  However, your insurance company has contracted an $80.00 per visit charge for its customers.  A specialist billing the patient for the $20.00 difference would be considered “balance billing”.

Balance billing is illegal for all approved Medicare services you receive from a provider. Additionally, 47 states have laws that require contracted/preferred/in-network, health care providers to seek payment only from the health plan and not from their patients.  These laws vary from state to state and may include only some types of health plans.  Some state laws restrict balance billing from out of network providers, as well.

Balance billing does not include your doctor or other provider charging or collecting out-of-pocket expenses such as deductibles, copayments, or co-insurance that may be required by your health plan.  Your state’s ban on balance billing usually does not apply if you have an elective procedure, such as cosmetic surgery, which is not a covered benefit. Additionally, you may be liable for the complete bill or a balance if you get an out-of-network service that is not an emergency and has not been approved by your health plan.

If you cannot resolve the issue with your health plan or doctor’s office, file a complaint with your state’s insurance department or Attorney General.