Balance billing and double billing are two distinct billing practices that can both harm patients, but they work differently. Balance billing occurs when an out-of-network provider charges you the difference between their full fee and what your insurance pays—a legal practice in some cases but heavily restricted since 2022.
Double billing, in contrast, is fraudulent: it happens when a provider or billing company attempts to collect on a medical bill that has already been paid by you, your insurance, or a government program like Medicare. These two problems can appear the same on a bill but require different responses. Understanding which one you're facing determines what protections apply to you and what action to take.
Table of Contents
- What Balance Billing Is and When It Happens
- How Double Billing Differs—and Why It's Illegal
- The No Surprises Act—What Balance Billing Is Banned For
- What's Still Not Protected by Law
- What to Do If You Receive a Balance Bill
- When Providers and Insurers Dispute the Amount
- Frequently Asked Questions
What Balance Billing Is and When It Happens
Balance billing occurs when an out-of-network provider bills a patient for the difference between the provider's full charge and the amount their insurance pays, according to HealthInsurance.org. For example: you receive emergency surgery from an out-of-network surgeon; the surgeon charges $15,000, your insurance pays $8,000, and the surgeon bills you $7,000.
That $7,000 difference is the balance bill. Balance billing was once common and patients had little protection. Today, federal law limits when providers can legally bill you this way. If you're being balance billed, the first question is whether your service is protected by the law that restricts this practice.
How Double Billing Differs—and Why It's Illegal
Double billing in healthcare refers to companies attempting to collect on medical bills that have already been paid by the consumer, insurance, or government programs such as Medicare or Medicaid, according to Resilient MBS. This is fraud, not a legal billing practice. Double billing typically happens after a claim has been settled.
Your insurance paid the provider, the provider was supposed to accept that as final payment, but they send you a bill anyway—or they bill your insurance twice for the same service. Double billing on Medicare claims violates the federal False Claims Act and can trigger CMS audits, civil and criminal penalties, and prosecution of healthcare providers or billing companies, according to CMS enforcement standards. If you suspect double billing, you are not responsible for paying, and you should report it.
The No Surprises Act—What Balance Billing Is Banned For
The No Surprises Act (Title I of the Consolidated Appropriations Act, 2021) became effective January 1, 2022, and bans balance billing for emergency services, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services, according to CMS. This federal law protects patients in three key situations: (1) emergency care at any hospital; (2) non-emergency care from an out-of-network specialist while you're at an in-network facility (for instance, an anesthesiologist during your surgery); and (3) transport by air ambulance.
Under the No Surprises Act, patients receiving protected services can only be charged their in-network cost-sharing amount (copayment, coinsurance, or deductible), and the insurance plan must pay any additional costs directly to providers rather than billing the patient, according to CMS. In other words: if your service is protected, you owe only what you'd owe if the provider were in-network. The provider must accept the insurance payment for the rest, even if it's less than their full charge.
What's Still Not Protected by Law
Balance billing is still legal—and patients still bear the cost—in two major situations. Balance billing remains legal in two major areas: ground ambulances and elective out-of-network services (services patients choose to receive from out-of-network providers at facilities without in-network alternatives), according to CoveredUSA. If you deliberately seek care from an out-of-network provider when in-network options were available, the provider can legally balance bill you.
Ground ambulances (by contrast to air ambulances) are not covered by the No Surprises Act, so you can be balance billed for them. Before providing an unprotected service, providers must give patients a notice of consent that discloses which services are not covered by balance billing protections and must remind patients they cannot waive their No Surprises Act rights, except through valid prior authorization in limited circumstances, according to CMS. If you were not notified before receiving the service, the provider's right to balance bill is weaker.
What to Do If You Receive a Balance Bill
Start by checking whether your service should be protected. If you received emergency care, non-emergency care from an out-of-network provider at an in-network hospital, or were transported by air ambulance, you are likely protected and should not pay a balance bill. Contact your insurance plan and the provider to dispute the bill and reference the No Surprises Act.
If your service is not protected—for example, you chose an out-of-network provider for elective care—you still have options. Ask the provider for an itemized bill and an explanation of the charges. Check whether the bill includes costs your insurance already paid (a sign of double billing). Request financial assistance programs if the bill is unaffordable. If you believe the bill involves double billing or other fraud, report it to your state's attorney general's office or to CMS.
When Providers and Insurers Dispute the Amount
When a balance billing dispute arises between a provider and an insurance plan over how much should be paid, neither the patient nor the provider decides the outcome alone. When balance billing disputes occur between providers and insurance plans, the No Surprises Act establishes an Independent Dispute Resolution (IDR) process administered by CMS-approved entities, where a neutral arbiter determines the final payment amount owed to the provider, according to CMS.
In an IDR case, a neutral third party reviews both sides and sets the price—and the patient is not part of that case. However, you should not receive a balance bill while the dispute is being resolved.
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Frequently Asked Questions
If I receive a balance bill, do I have to pay it?
Not necessarily. If your service is protected by the No Surprises Act (emergency care, non-emergency at in-network facilities, or air ambulance), you should not pay. If your service is not protected, ask for itemized details and check for double billing before paying.
What's the difference between balance billing and double billing?
Balance billing charges you the gap between a provider's fee and what insurance pays. Double billing is fraud—attempting to collect on a bill already paid by insurance or you.
Can a provider balance bill me if they didn't notify me in advance?
Providers must give written notice before providing unprotected services. If you received no notice, the provider's right to balance bill is significantly weakened, and you should dispute the bill.
What happens if a provider keeps balance billing after I dispute it?
Report the provider to your state's attorney general's office or to CMS. If it's double billing (collecting on already-paid claims), also report it as potential fraud under the False Claims Act. —