Balance Billing Definition

Balance Billing occurs when a healthcare provider bills a patient for the difference between the provider’s charge for a service and the amount paid by the patient’s insurance plan. This situation typically arises when the provider is out-of-network with the patient’s insurance plan, and the insurer’s reimbursement does not cover the full cost of the service. In balance billing scenarios, patients may be responsible for paying the remaining balance after their insurance company has processed the claim and paid its portion.

Balance billing can result in unexpected medical costs for patients, especially if they receive care from out-of-network providers or for services that are not fully covered by their insurance plan. Some states have laws restricting balance billing practices, especially in emergency situations or for involuntary out-of-network services. Patients should review their insurance policies and understand their rights regarding balance billing to avoid unexpected financial liabilities related to healthcare services.