Balance billing occurs when your out-of-network healthcare provider bills you for the difference between their charges for the service you received and the amount your insurance plan has established as the allowed amount. If your health insurance coverage does not include out of network services, you will be billed for the entire provider charge.
- Your doctor charges $6,000 for a surgical procedure. Based on the negotiated contract between your insurance company and the doctor, the allowed amount is $3,500. Your deductible is $1,000. That leaves $2,500 between the deductible you owe, and the total allowed amount. Your insurance plan will pay the $2,500.
- If your doctor is in-network, he or she will accept the $3,500 ($1,000 deductible and $2,500 insurance payment) as payment in full, and the doctor cannot ask you for the remaining difference between the $3,500 allowed amount and the doctor's full charge of $6,000 (another $2,500).
- If your doctor is out-of-network, your insurance company might pay $2,500, but will more likely pay nothing or something less. In most cases you will be billed for the remaining balance of at least $3,500. ($6,000 charge minus the insurance payment of $2,500 leaves a $3,500 balance.)
In-network providers do not balance bill
If you are seeing an in-network provider, you will not be billed for amounts above the negotiated rate that the provider and insurance plan have agreed to (sometimes called the "allowed amount"). By law, insurance companies operating in New Hampshire must prohibit provider balance billing in their network participation contract with health care providers.
Out-of-network providers do not have a payment agreement with your insurance company, meaning they can bill you for any amount. If you receive care from an out-of-network hospital, there is virtually no limit on what you may be liable to pay. Learn more about the difference between in-network and out-of-network providers.
During the 2018 session, the New Hampshire Legislature acted to prohibit anesthesiologists, pathologists, radiologists, and emergency physicians from billing a commercially insured patient for their charges when the care was provided at an in-network hospital. Therefore, as long as you have chosen an in-network hospital, you should not owe more to any of these provider types than your copayments, coinsurance, or deductible, as if the care had been provided by an in-network provider. In addition to the hospital, you should confirm that your surgeon, assistant surgeon, or other doctors seen in the hospital are in-network, or you may face out of network charges from these providers.