What is Balance Billing?

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The amount left after you have paid your deductible and your insurance plan has paid for the medical services you received as per the terms & conditions of your policy is known as Balance Billing. In other words, it’s the difference between the total cost of the services you are charged for and the amount your insurance plan pays. 

How Balance Billing works?

Let’s assume that you go to the doctor and get treatment. At the time of receiving the treatment, you pay your deductible and your insurance plan supposedly covers the rest. Now, as per the process, you have paid all your bills for the treatment. But months later, you receive a bill from your doctor for the amount your insurance plan didn’t cover. And, this bill is the Balance Billing. 

Although it seems like you have been charged extra as per the terms used, you are simply paying for the services you received. It’s just the amount that your plan didn’t cover!

A balance bill can be quite triggering for a patient, especially if it’s a large amount. However, you need not worry as your healthcare provider can help you understand the same. Let’s know what healthcare professionals can do to make sure that the patients aren’t confused about the balance billing!    

What healthcare providers can do?

While balance billing may come as a surprise for patients, especially when they are unaware of it, healthcare providers count on it as far as revenue is concerned. 

  • Being a medical services provider, you need to make sure that the patients’ care always stays on top so that they do not care whether you fall under their insurance plan’s network or not! In that case, even if there are stances of balance billing, patients may not care much about it as they are getting the desired services at their comfort.    
  • Healthcare providers need to make sure that patients are well informed about the balance billing. It will not just improve their trust in you, but inspire them to continue with your medical services instead of giving much importance to balance billing. 

Although no patient would like to experience balance billing as nobody wishes to pay extra, if your patients are well informed at the time when they are taking your services, it will solidify their trust in you as their medical services provider. 

What can patients do?

Patients should not confuse balance billing with other billing and insurance terms such as deductible, copays, and coinsurance. Knowing these terms would help them understand the concept of balance billing better. 

  • Deductible – The ‘minimum’ amount you need to pay out-of-pocket to your healthcare provider before your insurance policy starts paying for your treatments is known as Deductible.
  • Copay – The fixed amount you directly pay to your healthcare provider on every visit, regardless of the treatment you receive is called a copay.
  • Coinsurance – The cost that remains after your insurance policy pays for your treatment as per the policy’s terms & conditions is called coinsurance. 

When do you receive Balance Billing?

Balance billing usually does not happen with in-network healthcare providers as the insurance company takes care of the bills and the patient is already aware of the charges. It generally happens when an out-of-network healthcare provider bills a patient for the services that are not covered by his/her insurance plan. The patient may not be aware that the services s/he has received are out-of-network even though s/he received it at an in-network healthcare provider.

Reasons when you are likely to get balance billing:

  1. Visiting an in-network healthcare provider and receiving service/s that are not covered by your insurance policy lead to balance billing.
  2. Visiting an out-of-network provider and the provider bills you for the amount that your insurance company did not pay.
  3. When an in-network provider moves out-of-network of your insurance plan and you take services without knowing the provider’s network status. 
  4. The doctor that treats you at your in-network hospital chooses to no longer participate in your insurance plan’s network. 


There are some general questions asked by patients regarding the balance billing. Let’s take a look at some of them.

1. Is balance billing legal?

Ans. A medical provider has the right to bill you for any amount that is not paid by your insurance. As a patient, you should be aware of all the costs that your insurance plan covers after paying your deductible.

2. How can I not receive balance billing?

Ans. The healthcare providers will not charge you unnecessarily for any service that’s been paid and covered by your insurance. However, if you wish not to receive any balance bills, you need to stay updated with your insurance plan. Having complete knowledge about your insurance policy will allow you to know the list of in-network healthcare providers and the list of services covered under it. So, when you know that you are going to an in-network or out-of-network healthcare provider and whether the services you need are covered by your insurance plan or not, you are unlikely to get a balance bill.

The other best way to avoid it simply by asking your healthcare provider upfront whenever you go for a treatment. You can ask whether a particular doctor who is attending you is in-network or not and the services you need are covered by your plan or not.

3. Do all treatments have or can fetch balance billing?

Ans. A healthcare provider cannot bill you for medically necessary treatments. However, if you have taken any medically unnecessary treatment, the provider may bill you for it as insurance generally does not cover medically unnecessary treatments.