By Healthcare Brew Staff
less than 3 min read
Definition:
Balance billing occurs when an out-of-network provider sends patients the unpaid balance for a bill not covered by their insurance. While some plans cover out-of-network care, they only pay providers based on their “reasonable and customary” fees, which limit how much out-of-network care is covered. The provider will then bill the patient for the difference.
What is “surprise billing”?
Ever get a healthcare bill that…surprised you? Then you might have experienced “surprise billing,” which is a specific type of balance billing where patients go to an in-network facility, but unbeknownst to them, are seen by an out-of-network provider that they then have to pay more for. The bipartisan No Surprises Act, enacted in 2022, was created to protect patients in most cases where they may have previously received a surprise bill, including for emergency care or care at an in-network facility—though ground ambulance rides are not covered.
What were some criticisms of the No Surprises Act?
Initially after the law was passed, providers alleged in 2023 that insurers weren’t paying them back and there was a backlog of claims. And the American Hospital Association and American Medical Association were vocal about their opposition to the bill via a lawsuit filed against the federal government in 2021. In February 2025, for instance, UnitedHealthcare of North Carolina had to pay a $3.4 million fine when it was found the insurer hadn’t protected patients from balance billing costs.
How have providers benefited from the No Surprises Act?
A 2024 Fair Health analysis looking at 45 billion commercial insurance claims between 2019 and Q3 2023 found that in-network care jumped, and an AHIP/BCBSA survey of payers found that the law had prevented 10+ million unexpected bills in the first three quarters of 2023. The Brookings Institute also found in the first half of 2023 that providers benefited from the law, receiving higher payouts than typically received from Medicare and in-network payers.
