Balance Billing: What It Is and How to Fight It
Reviewed by BillFighter · Checked against the laws and agency sources cited on this page
Balance billing is when an out-of-network provider bills you for the difference between its charge and what your insurance paid. Since January 1, 2022, the federal No Surprises Act bans it for emergency care, for out-of-network providers you did not choose at an in-network facility, and for air ambulances. In those cases you owe only your in-network cost-sharing, and you can dispute the rest in writing.
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. Read your EOB.
Step 2: Dispute It in Writing
The dispute goes in writing. It cites the No Surprises Act (Public Law 116-260, Division BB), names the scenario that applies, and asks for the balance-billed amount to be removed and the bill corrected to your in-network cost-sharing. BillFighter's Dispute Letter says exactly this, in your name, when the scan flags a surprise bill. You read it, sign it, and mail it yourself, or have BillFighter send it by certified mail with the delivery record on file. That record is what you'll need if you have to report the violation. Start with the free scan: Check my bill, free →
Step 3: Calling Is Optional
You don't have to call. If you want to confirm the billing address, you can call the billing department. Ask them to put anything they tell you in writing, and note the date, the time, and the name of the person you spoke with. Nothing said on the phone replaces the letter.
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. Your state's protections.
What BillFighter does here
Upload the bill and, if you have it, the EOB. BillFighter flags charges that show the signs of surprise billing — an out-of-network emergency charge, an out-of-network anesthesiologist or radiologist at an in-network hospital, a balance billed above the insurer's allowed amount. Then it drafts, in your name, the dispute letter that cites the No Surprises Act and asks for the balance to be corrected to your in-network cost-sharing. You read it, sign it, and send it: mail it yourself, or have BillFighter send it by certified mail.
BillFighter reads your documents, prepares the letters that fit, and keeps the case organized. With the Fight Kit, you print and mail the letters. With In Your Corner, BillFighter mails up to two of your approved letters by certified mail and tracks delivery. You review every draft. BillFighter does not call or negotiate with the other side, and it is not a law firm. Check my bill, free →
See a sample letter: Medical bill dispute letter sample →
Common questions
Is balance billing illegal?
Often, yes. The No Surprises Act bans balance billing for emergency care, for out-of-network providers you did not choose at an in-network facility, and for air ambulance rides. Outside those three cases, your state's law may still protect you.
How much can I be charged on a surprise out-of-network bill?
Only your in-network cost-sharing: the copay, coinsurance, or deductible you would owe an in-network provider. The provider may not bill you for the rest.
Where do I report a balance-billing violation?
File with your state insurance department, with the Centers for Medicare & Medicaid Services (CMS), which enforces the federal act, and with the CFPB if the bill went to collections. Providers who violate the act can face penalties of up to $10,000 per violation.