Is balance billing legal?

It depends on the provider's relationship with the plan and the kind of care. A preferred, in-network provider may not balance bill for covered services. A Medicare provider that does not participate can charge no more than the limiting charge, set by law at 115 percent of the non-participating payment amount. The No Surprises Act bans it for emergency care, for non-emergency care from out-of-network providers at in-network facilities and for air ambulance services. Outside those limits, and any state law that applies, it can be allowed.

What Is Balance Billing?

Balance billing

Short answer

Balance billing is billing a patient for the difference between the provider's full charge and the amount the payer allowed, on top of the deductible, copay or coinsurance the patient already owes under the plan.

Last reviewed October 30, 2026 by the Remitwright billing team. Editorial policy

Also written asbalance billbalance bills

Balance billing is sending the patient a bill for what the plan did not allow. If the charge is $250 and the allowed amount is $160, the $90 difference is the balance. Whether you may bill it depends on your relationship with the payer. A preferred provider has agreed to accept the allowed amount for covered services, so the gap becomes a contractual adjustment and the patient owes only the cost sharing the remittance shows.

Out of network, the room to bill the difference is narrower than it used to be. Medicare caps what a non-participating provider can charge at the limiting charge, set by law at 115 percent of the payment amount for a non-participating provider, which works out to 109.25 percent of the regular fee schedule amount⁴. Since January 1, 2022, the No Surprises Act has protected patients from these bills for emergency care, for non-emergency care by out-of-network providers at in-network hospitals, hospital outpatient departments and ambulatory surgical centers, and for air ambulance services². In those cases the patient pays in-network cost sharing, and a provider who thinks the plan paid too little takes it up with the plan.

The mistake is sending a statement before checking which rule applies. Read the group code on the remittance, check whether the No Surprises Act protects the claim, and bill the patient only for what the payer assigned to patient responsibility unless you are free to bill more.

Example

Balance billing in practice

An out-of-network assistant surgeon bills $1,200 for a case at an in-network hospital and the plan allows $700. The No Surprises Act covers this care and an assistant surgeon cannot ask the patient to waive it, so the patient owes only in-network cost sharing and the surgeon takes any dispute over the $500 gap to the plan. Hypothetical example.

Balance billing

Balance billing in practice

Balance billing is part of out-of-network billing, one of the services a dedicated biller runs for you.

Questions about balance billing