When might balanced billing be illegal?

Balanced billing can be illegal when it involves a participating provider, which refers to healthcare providers who have agreements with insurance companies to provide services at negotiated rates. When a patient has insurance that covers part of the cost of care, the participating provider is generally obligated to accept the insurance payment as full payment for covered services. Imposing additional charges beyond the agreed-upon rates—such as billing the patient for the remaining balance—would be in violation of the contract with the insurance company and could be considered a deceptive practice.

In contrast, for non-participating providers or in certain situations with other types of facilities, the rules regarding balanced billing may differ. For instance, hospitals or free-standing diagnostic laboratories might have different agreements that allow for balance billing under specific conditions, depending on state laws or the particular contracts in place. Therefore, understanding the context of participating providers is crucial to grasp when balanced billing might cross the line into illegality in the healthcare landscape.