DEFINITION: Balance billing occurs when providers bill a patient for the difference between the amount they charge and the amount that the patient’s insurance pays. The negotiated rate that insurers pay providers is almost always less than the providers “retail price.” Some providers will bill the patient for the difference, or balance; this is called balance billing.
Providers that are in-network have agreed to accept the insurance payment as payment in full (less any applicable copays), and are not allowed to balance bill the patient. However, balance billing is allowed if the provider is not in your insurance network. (Your insurance carrier might pay the provider based on your out-of-network coverage, but the provider is able to balance bill as well.)