What is Balance Billing?

Balance billing is sometimes called surprise billing. In the world of health insurance, balance billing is one of the worst situations you may experience. Also, it can happen on almost any health plan in the United States. Federally, there are no laws against balance billing on ACA-compliant health plans. Some states, like Nevada, recently passed legislation to ban balance billing in certain areas and in certain situations.


Balance billing occurs when you receive care at an in network facility, but the provider treating you is out of network on your health plan. Your insurance will cover the in network facility charges. The out of network provider will send you a bill outside of your insurance plan for what they want to get paid.

Simply put – even if you go to the in network facility you are supposed to go to, your claim can still get billed out of network depending on the contract status of the overseeing physician.

There are certain types of providers who are notorious for sending balance bills. Here are some of the most common providers who balance bill:

  • Radiologists
  • Anesthesiologists
  • Pathologists
  • Emergency Room Doctors

Balance bills can cost tens of thousands of dollars and do not apply to the in network benefits on your plan.

How To Avoid Balance Bills?

Avoiding balance bills can be difficult, but it is possible to do. On your health plan, you have a network list. You need to make sure you verify every doctor’s contract status on your health plan. This can sometimes be difficult. If you are in an emergency situation, the last thing you want to do is check the network list of your health plan.

The issue of balance billing occurs for a handful of reasons. The main reason that causes balance billing – your insurance carrier has a small network or does not reimburse doctors at a high rate. If the insurance plan does not pay doctors well, they may not accept the contract of your health plan, which can lead to balance billing. It is important to talk to a broker about this. Some insurance plans are notorious for small networks and low reimbursements, which leads to an increased risk of balance billing.

Fortunately, the State of Nevada recently passed legislation in 2019 to make Emergency Room balance billing illegal in Washoe County and Clark County. This legislation will be phased in over the course of a 3 year period starting in 2020.

Your Rights

Fighting balance bills is tough and has a low success rate. Based on national statistics, roughly 1 in 5 people who go to their preferred in network hospital on their health plan still get balance billed. You can fight a balance bill by submitting 1 or 2 internal appeals with your insurance company. During the appeals process, insurance companies will review the situation to determine if they can pay the doctor more money to offset or negate the balance bill. Ultimately, the doctor decides whether or not to play ball and rescind the balance bill.

Your last option is to file a complaint with the Nevada Division of Insurance. You can fill out a complaint by clicking here.