What is meant by "balance billing" in the context of healthcare compliance?

Balance billing occurs when a healthcare provider bills a patient for the difference between what the insurance company pays and the total amount charged for medical services. In scenarios where a provider is out-of-network or when a patient's insurance does not cover the full cost of care, the provider may seek to collect the remaining balance directly from the patient. This practice raises compliance issues, particularly when insurance policies or state laws have specific regulations about how and when a patient can be billed for the balance.

In focus on why this concept is significant in healthcare compliance, it's important to note that certain regulations and laws, such as the No Surprises Act, protect patients from unexpected balance billing in emergency situations or when receiving care from out-of-network providers without prior consent. Understanding balance billing is crucial for healthcare providers to ensure they adhere to these compliance regulations and maintain ethical billing practices that safeguard patients from unexpected costs.