Health Insurance
Balance Billing
Balance billing can result in unexpected medical bills, particularly when receiving care from out-of-network providers or facilities.
Last reviewed: May 2026 · Editorial methodology
Definition
Balance billing occurs when a healthcare provider charges a patient the difference between their billed amount and the payment received from the insurer. For example, if a surgeon charges $5,000, the insurer pays $2,000 based on its UCR rate, and the provider's contracted agreement would have written off the rest — but the provider is out-of-network, they may bill the patient the remaining $3,000. The No Surprises Act, which became effective January 1, 2022, and whose enforcement mechanisms were strengthened through 2026 rulemaking, prohibits surprise balance billing in emergency settings and for certain non-emergency services at in-network facilities provided by out-of-network ancillary providers such as anesthesiologists and radiologists. In those protected situations, patient cost-sharing is limited to the in-network rate. Balance billing protections do not apply to all out-of-network scenarios — particularly scheduled services at out-of-network facilities that you chose voluntarily. Some states provide additional balance billing protections beyond federal law.
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Cover Forge USA Editorial Team
Editorial Lead
This article was researched and written by the Cover Forge USA editorial team against federal sources (NAIC, CMS, FEMA, DOL, SSA, state DOIs) and standard policy forms. Bylines organize content by topic — they do not assert individual licensure. See our editorial-policy for details.
Reviewed 2026-06-14
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