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Balance Billing (And What To Do About It)


"Balance billing" is when the insurer pays a part of a health care bill, and you are billed for the rest. The classic example is when a patient uses a doctor outside of the insurer's network when the patient does not know the doctor's status or when the patient is in no position for ask. For example, you may choose a surgeon who is in network, but he or she may use an anesthesologist for the operation who is not in your insurer's network. Or you may be unconscious and in no position to ask.

If this happens to you, take the following steps:

  • Step 1. Check to see if you are being billed by a health care provider who is in your network for a service that is covered by your insurance plan. If so, the insurer should pay the bill.
  • Step 2. If the bill is from a doctor not in the network, contact the insurance company. Explain that this was an involuntary use of an out-of-network provider, and that you made a good faith effort to only use in-network doctors. Ask the insurance company to pay the bill.
  • Step 3. If the insurance company will not pay the bill, check the law in your state. It may prohibit balance billing.
    • To learn the law of your state, go to The Actors' Fund Of America's Health Insurance Resource Center ( offsite link, click on your state, then click on "Insurance Guides" and/or Complaints/Appeals).
    • If you have difficulty, contact your Department of Insurance for guidance. There may be a regulation which prevents balance billing in your situation. For example, in California, there is a regulation which makes it illegal for people covered by an HMO (Health Maintenance Organization) to be balance billed for out-of-network emergency services. If there is such a law/regulation in your state, call the insurance company and the doctor and remind them of it. For your state's insurance department contact information see: offsite link. Click on "NAIC States and Jurisdictions."
  • Step 4. If there is no such law or regulation in your state, don't pay the bill and expect to get it back from the insurance company. Instead, ask the insurance company to work through the situation on your behalf to eliminate or reduce the bill.
  • Step 5. If there is no compromise reached and you continue to receive a bill, file an appeal with your insurance company to get the company to pay all, or at least a large part, of the bill. At the same time, try to negotiate a reduction in the bill with the health care provider or hire a professional to do the negotiation for you. 
    • For information about professionals who negotiate medical bills, click here.
    • For information about negotiating a hospital bill, click here.
    • For information about negotiating a doctor's bill, click here.

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