Balance Billing: What It Is and How to Fight It

You go to an in-network hospital. You do everything right. Then weeks later, a bill arrives from a doctor you've never heard of — an anesthesiologist, a radiologist, a consulting specialist — who happened to be out-of-network. The charge is thousands of dollars.

This is balance billing — and for decades, it was perfectly legal. Patients had almost no recourse. That changed with the No Surprises Act, which took effect January 1, 2022.

What Is Balance Billing?

Balance billing happens when an out-of-network provider bills you for the difference between their charge and what your insurance paid. For example:

• The provider charges $5,000
• Your insurance pays $2,000 (their allowed amount for out-of-network)
• The provider bills you for the $3,000 "balance"

This was especially common in emergency rooms, where you have no ability to choose your providers, and in situations where out-of-network specialists treated you at an in-network facility.

How the No Surprises Act Protects You

The No Surprises Act prohibits balance billing in three key scenarios:

1. Emergency Services

You cannot be balance-billed for any emergency care, regardless of whether the facility or provider is in-network. This includes the ER visit, stabilization, and any post-stabilization care until you can be safely transferred.

2. Out-of-Network Providers at In-Network Facilities

If you go to an in-network hospital but are treated by an out-of-network provider you didn't choose (anesthesiologist, pathologist, radiologist, etc.), you're protected. You can only be charged your in-network cost-sharing amount.

3. Air Ambulance Services

Out-of-network air ambulance providers cannot balance-bill you beyond your in-network cost-sharing amount.

What to Do If You Receive a Surprise Bill

Step 1: Identify the Violation

Check your EOB and the bill. If the provider is out-of-network but the service falls under the No Surprises Act protections, the balance bill is illegal.

Step 2: Contact the Provider

Call the billing department and inform them that the charge violates the No Surprises Act. Reference the specific protection that applies. Many providers will back down at this stage.

Step 3: File a Written Dispute

If the provider doesn't remove the charge, send a formal dispute letter via certified mail. Cite the No Surprises Act (Public Law 117-169) and the specific scenario that applies. Request removal of the balance-billed amount.

Step 4: Report the Violation

File a complaint with:

• Your state's insurance department — they enforce state-level protections
• The Centers for Medicare & Medicaid Services (CMS) — they enforce the federal No Surprises Act
• The Consumer Financial Protection Bureau (CFPB) — if the bill has been sent to collections

Providers who violate the No Surprises Act face penalties of up to $10,000 per violation.

State Protections May Offer More

Many states had surprise billing laws before the federal act, and some provide broader protections. Check your state's specific rules — you may have additional rights beyond what federal law provides.

Fight Back With BillFighter

Upload your bill to BillFighter and our AI flags potential balance billing violations, generates dispute letters citing the No Surprises Act, and sends them via USPS certified mail.

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