Balance billing is billing the patient for the difference between your charge and the plan's allowed amount. For in-network care it's generally prohibited by your contract. For many out-of-network emergency and facility-based situations, the No Surprises Act now prohibits it and routes the provider-plan payment dispute to federal IDR instead of the patient's pocket.
When it's allowed vs. prohibited
- In-network: generally prohibited — your contract limits the patient to their cost-share of the allowed amount.
- Out-of-network, non-emergency, no NSA protection: may be allowed, subject to state law.
- Emergency and many out-of-network-at-in-network-facility situations: prohibited under the No Surprises Act.
The No Surprises Act change
For surprise out-of-network bills the No Surprises Act protects the patient: they owe only their in-network cost-sharing, and the provider and plan resolve the rest through open negotiation and, if needed, federal Independent Dispute Resolution — not by billing the patient the balance.
The dispute moves to IDR, not the patient
Frequently asked
Can I balance-bill an in-network patient?
Does the No Surprises Act ban all balance billing?
Primary sources: CMS — No Surprises Act / balance-billing protections. General information, not legal or medical advice — confirm against the governing rule for the plan type.
When the appeal has to be written, and cited
Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.