Balance billing for your medical practice

Skyline Medical Billing Management discusses balance billing for your Prescott medical practice

As a medical provider, a significant part of your business is medical billing and working with insurance companies. This is not typically considered glamorous or fun work to do, but it is necessary. One drawback of this payment model and system is that you can end up footing the remainder of a bill if the client meets their deductible and the insurance company meets their requirements. Skyline Medical Billing Management discusses balance billing for your Prescott medical practice.

Is it legal?

It may be tempting to bill your client for the remainder of a bill, but in some cases, this is illegal or could open you up to legal action for breach of contract with an insurance provider. The legality depends on state law and your agreement with insurance companies. A few situations where it is usually illegal to balance bill are when you accept Medicare, Medicaid, or you have a contract with an insurance company and bill more than the contract allows.

Under what circumstances?

However, there are circumstances where balance billing is perfectly legal. These situations typically involve out-of-network clients and procedures that are not covered by the insurance provider. If you are doing procedures that are not medically necessary, you may consider alternative billing methods such as receiving a portion of the bill prior to a procedure.


 If your practice is out-of-network with the insurance company/patient’s plan, you can balance bill the patient for the FULL charged amount – not what the insurance company allows.

Example: The doctor’s office bills a patient’s insurance $150.00 for an office visit (99204). The EOB comes in showing the insurance company allowed $102.50 toward the patient’s out-of-network deductible. Because the doctor is not contracted with the insurance company or the patient’s plan – in other words, not bound by in-network rate agreements – the doctor can balance bill the patient for the full $150.00.

Do your research

Before you decide to balance bill a client, be sure that you are up-to-date on state law and are familiar with your insurance provider contracts. Have your billing practices reviewed by an experienced attorney and medical billing expert to ensure your medical practice remains compliant. Additionally, consider that many clients will be unable to pay the remainder of their bill, and negotiating with a client may result in a more favorable outcome for your you.

If you have questions regarding balance billing or general medical billing for your Prescott practice, call Skyline Medical Billing Management at 928-227-1167.

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