What is Balance Billing?

You may come across the term “balance billing” in your healthcare insurance paperwork. Balance billing is the amount you must pay after your deductible, copayment, and coinsurance have been applied to any bill and your insurance company has paid their obligation. Any remaining amount on the bill is your responsibility and you are balance billed for that amount.

There are times when balance billing is legal and times it is not.

Here are examples of legal balance billing:

Man Paying Bill

  • When you use a healthcare provider outside of any network you are using because of your insurance coverage. Your plan might pay some out-of-network costs, but these providers are not obligated to accept those payments as paid-in-full since they aren’t participating in your network program. They can balance bill you for any remaining amount.

When is balance billing illegal?

  • If you are billed by a provider when you have Medicare and that provider has accepted Medicare assignment.
  • If you have Medicaid and your provider has an agreement with them.
  • If your provider has any contract with your health insurance plan and they bill you more than the plan allows.

In these cases, you need to investigate the excess charges and determine why you are being billed. Keep in mind that each state regulates its health insurance plans so you should investigate what rules apply where you live. Also, it is important to note that insurance companies that pay some out-of-network costs are not required to pay a percentage of what the provider billed you, but rather they are only obligated to pay a percentage of what they deem “reasonable and customary” for the services you received. Therefore, you might see a higher bill than you expected for out-of-network care. It is important to stay in your healthcare network as much as possible.

First Day Films can help untangle the complexities of healthcare billing and services with our employee benefits videos. We also offer open enrollment and workplace videos. For more information on our video services please call 833-422-7332.