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Balance Billing

Every health organization has a standard fee schedule that it discounts for volume health services payers such as Blue Cross or Aetna.  When one agrees to accept a discounted fee schedule, it is not legal to bill the patient the difference between your standard fee schedule and the discounted fee schedule. This practice is called balance billing and is only allowable if you do not have a contract with the payer.

The slight exception to this rule is Medicare, which regulates the amount above the Medicare allowable that you may bill the patient, but only if you are a non-participating provider.  If you are a participating provider with Medicare, you may only bill the patient for their unmet deductible and for co-insurance which is 20% of the allowed amount.

A health care organization’s attempt to collect from the patient the difference between the standard charge amount and the allowed amount approved by a contracted carrier such as Medicare. Balanced billing is a contract violation and may be illegal. The practice should be avoided.