Balance billing is essentially the health care provider’s ability to collect from the patient any remaining balance of their charges after third party payer responsibilities.  This can include both deductible and self-pay amounts.  And for a “routine” emergency room visit, for example, this often involves multiple providers with LOTS of patient balance billing.  This has become particularly pronounced with today’s high deductible plans.  This often leads to confusion and friction between payers, patients and providers and leaves patients with unanticipated healthcare bills that have substantial financial effects.

Often complicating this confusion and friction are certain billing practices mandated by Federal  and State insurance entities, and the use by many providers of outside companies to perform their billing. As payer rules and requirements have become very complex, many health care providers turn to these outside billing companies that specialize in dealing with reimbursement issues.  This often leads to patients and payers interacting directly with the billing company to resolve issues, rather than dealing directly with the provider.

To avoid some level of anxiety about what and how a patient will be required to pay for their health care services, it helps to know as much as you can about the practice of balance billing. Below are 10 things you, the patient, should know:


  1. Your health care provider might not even be covered by your insurance. This is usually referred to as an “out of network” provider. Patients might be unaware they have received out of network care until the bill arrives in the mail. It is estimated over 60 percent of patients with out of network bills were unaware their provider did not participate with their insurance.
  2. Even if your Hospital is “in network,” your physician(s) might not be. Hospitals often use independent physician groups for services such as emergency medicine, pathology, radiology, anesthesiology, or surgery.  Any or all of these physicians might not be “participating” in your insurance plan.
  3. Your insurance payer might feel your providers’ fees are excessive. As a result, payers sometimes refuse to pay the provider’s full bill. When this happens, the patient often bears the remaining financial responsibility.
  4. Insurance payers are increasingly narrowing the number of providers who participate in their networks by demanding acceptance of lower fees. This is leading to an increase in inadvertent out of network patient responsibility.
  5. Balance billing is progressively increasing. It has been reported from the Consumers Union that nearly a third of insured Americans received an unanticipated bill when their health plan paid less than they expected.
  6. Consumers are paying more attention to their medical bills and are speaking up about it. However, they are unaware of exactly how to dispute the surprise medical bills. This often, appropriately, starts with contacting the phone number for “billing questions” on the statement.  Be prepared.  Have the statement, the date of service and a copy of any insurance correspondence handy.
  7. If you do call regarding a billing question, the patient must be aware that they are often contacting a large back office operation, many times off shore, and the provider that treated them will likely be unaware that they have a concern.
  8. Any effective billing office will clearly be happy that you called, that you are expressing a concern and will WANT to determine a reasonable resolution. Be prepared to offer your solution.
  9. No one wins by not resolving a dispute. Being inattentive to an outstanding medical bill can often lead to the involvement of a collection agency and a blemish on a patient’s credit record.
  10. According to the Consumer Financial Protection Bureau, roughly half of all collection accounts on credit reports are due to medical debt, and these accounts can significantly damage consumer credit scores.