How This Balancing Act Will Leave You Tipped Over

You visit the doctor for a routine exam. The co-pay portion is paid on the spot and you assume that your insurance provider picked-up the balance. The next thing you know, you receive that familiar white envelope in the mail – a bill. But wait – you paid your portion, right?

What is Balance Billing?

In a controversial and sometimes illegal (in Illinois and many other states) practice, doctors and other healthcare providers perform “balance billing.[1]” “Balance billing” occurs when healthcare providers receive a discounted (unsatisfactory) payment from your insurer, and then bill you – the patient – directly for the difference between the amount charged and the amount the insurer paid.

I can see you saying out loud, “Only in healthcare.” Let’s relate to something else we might purchase – clothes at 30% off. You pay the clothing store using your credit card. They receive payment from your credit card company. The store then decides to send you a bill for the difference between the original price and the discounted price.  The amount they bill you is the “balance” of the charges.  Confused yet?  You should be.

As a healthcare consumer you need to be ready in case you are a victim of “balance billing.” First, if you have a health insurance plan, understand which providers are in the plan (in-network) versus those who are not (out-of-network).   Whenever you see your provider, ask them before your visit if they are in-network.  Next, when you do receive a bill, review the details to make sure that you are being given the network discount.

Regardless, if you receive a bill from an in-network or out-of-network provider that you are not expecting, call your insurer immediately. When it comes to getting your discount according to your insurance plan, your insurance company is your best advocate.  Ask for their help when it comes to working with network providers with whom they have contracts to make sure you receive the discount you are entitled to.

Insurers often include provisions in their contracts with providers that prohibit in-network providers from “balance billing” plan members. The confusion will come into play if the insurance company and the provider disagree on what is the actual discounted price. If the parties disagree, start communicating with both your provider and payer in writing so you have all the facts.  Patients who see out-of-network doctors typically have no protection against “balance billing.”  The issue in this area is that the health benefit plan also has provisions for paying usual and customary prices for out-of-network providers. Once again, if your payer and provider are in dispute, submit your questions in writing to both parties.

What happens when you didn’t choose the out-of-network provider (i.e. radiology, pathology, anesthesiology, and any contracted service that your in-network provider might not perform)? This is where it can get tricky. For patients in Illinois, a new law was passed in June 2011, which prohibits any provider from “balance billing.” Patients and consumers alike argued that, no matter how hard they try to seek care in-network, they may have no control over whether the doctors they see while in an in-network hospital are in the network.

What Does Balance Billing Look Like?

In a long running Illinois “balance billing” scheme, Dr. Janet Despot and Rickey Weir, her husband and office manager at the Cardinal Respiratory medical practice in Springfield, over-billed Medicare, private insurers, and patients by more than $800,000 from 1997 through 2007.[2]

Despot, 50, pleaded guilty to a misdemeanor charge of “balance billing” Medicare patients in February 2009. She didn’t receive jail time, but has paid a $10,000 fine and forfeited $2.5 million that will be used for restitution and additional fines.[3]

Readers, don’t fall victim to this balancing act! Look at your bills, contact your providers, and if anything looks off-balance, it probably is. Be your own best advocate with these three questions

  •  What procedure code am I being charged for?
  •   What is the price for that procedure code?
  •   What is the reasonable price reported by your payer for that procedure code?

Send me your thoughts and thanks for reading!


Rebecca S Busch

Patient Healthcare Advocate


To see a state-by-state comparison please visit Kaiser State Health Facts.




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Join the conversation
  • Alice Graham - June 7, 2012

    Working for the school system, I have healthcare benefits, and only visit doctors that are in network. I do make sure that they are in network before I visit by checking with the provider and the office. From my experiences at doctor offices, I have never been given the amount that the insurance company will be charged before I leave the office. I only know my co-pay. Haven’t had a problem with in network with billing balance. However, trouble is anticipated when, or if, a procedure is done and multitudes of doctors, anesthesiologists, and others, are used, that may or may not be on my in network plan. A colonoscopy for example. That’s a problem. It would be impossible to control personnel that are in network before a procedure. You could try for a scheduled procedure, but not in an emergency.
    I check the bills and the statements and make sure that they match the doctor visits. Thanks for the information.

    admin - January 21, 2013

    thanks for the feedback! always remember to ask your provider What CPT code did you charge me (CPT is the procedure code that tells you what was done) and what ICD code did you charge me (the diagnosis – which why someone treated you) each time you leave a provider!

  • Komal - June 28, 2012

    Because they have fallen for the lies and half trthus of the right.It surprises me that so many Americans seem not to be aware about Obama’s healthcare plans [a]. During the election, he campaigned for these changes stating that he felt it was unfair to have a system where insurance companies try to escape paying claims and was elected to bring in changes [b].First of all, too many people do not know that Obama wants to make insurance more available to all. His system is similar to that which works in Holland, Taiwan [c] and Switzerland. It works there and private healthcare companies provide most the insurance to the people there.FACT the USA spends more on healthcare PER PERSON than any other nation on the planet [d].FACT – insurance companies admit that they push up costs, buy politicians and do not pay out for many claims when they should [e].FACT the US has higher death rates for kids aged under five than western European countries with universal health coverage [f].That means that a dead American four year old would have had a better chance of life if they were born in Canada, France, the Netherlands, Cuba, Switzerland, Germany, Japan etc, all of which have universal health coverage. And no western European nation with universal healthcare has moved away from it. And the sad thing is, that the insurance companies have spent loads of money to fight these reforms [g] and loads of politicians are taking the thirty pieces of silver from them to fight the reforms, rather than fight for the health of the American people.Remember, I back my facts up with evidence. Those who say they are wrong tend not to. If they are wrong, e-mail me with proof and let me know.