Balance billing is a provider charging you the difference between what it billed and what your insurer paid. In network, providers agree not to do it: the negotiated rate is the whole price. Out of network there is no such agreement, and the gap lands on the patient.
When it is not allowed anyway. Federal law and New York’s rules limit balance billing in the situations where you had no realistic choice:
- emergency care, including at an out-of-network hospital
- an out-of-network clinician working inside an in-network facility — the anesthesiologist, radiologist, pathologist or assistant surgeon you never selected
In those cases you owe in-network cost sharing and the rest is settled between provider and plan.
How to recognize it. Put the bill next to your explanation of benefits. If the provider asks for more than the patient responsibility line, that is a balance bill, and if it fits a protected situation the number is not yours to pay.
The procedure for pushing back: surprise medical bills in New York.
Also called: balance bill, surprise bill. Reference: Balance billing on Wikipedia — general definition, not New York specifics.
More in Glossary of health coverage and billing terms
- Out-of-pocket maximum — The annual ceiling on what you pay for in-network covered care. After it, the plan pays 100%.
- Network (in-network and out-of-network) — The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.
- Formulary — The list of drugs a plan covers, sorted into tiers that determine what you pay.
This page explains how the system works. It is not medical advice. More.