When the provider charges you the difference your insurance won't pay.
Balance billing occurs when a doctor or hospital charges you for the remaining amount your insurance plan does not cover. This usually happens if you see an out-of-network provider who has no contract with your health insurance company. The provider may bill you for their full standard rate instead of the discounted rate your insurer pays.
Even if you visit an in-network hospital, you might be treated by individual specialists who are not part of your network. These can include anesthesiologists, radiologists, or pathologists who work as independent contractors. You often do not choose these doctors, but you receive a separate bill from them later.
The federal No Surprises Act now protects patients from most surprise out-of-network bills for emergency services and certain non-emergency care at in-network facilities. Under this law, providers cannot bill you more than your in-network cost-sharing amount. However, this protection does not apply to all types of healthcare services or facilities.
Do not pay a surprise bill immediately if you suspect it is inaccurate. First, call your insurance company to confirm if the charges violate your plan's network protections. You can also contact the hospital's billing department to request an itemized bill or to discuss a payment plan if you are struggling to afford the total amount.