Healthy Times

Term to Learn


Balance Billing
When you get services from doctors and hospitals that are not part of your health plan's network, you may come across balance billing.

What Is It?
It's the difference between what a doctor (or hospital) who is not in our network charges for a service—and what we agreed to pay.

If a doctor charges more than we agreed to pay, you may get a bill requiring you to pay that difference. We call that difference balance billing.

Last month Sidney went to see Dr. Smith, a doctor who is not in the Blue Cross Blue Shield of Massachusetts network, and had an outpatient surgery. Dr. Smith submitted a claim to us charging $300 for the surgery. We agreed to pay $200 for this surgery. This leaves Sidney with a balance billing amount of $100.

Sidney's total (not including co-insurance or deductible) for her surgery came to $250. Here's why:

Balance Billing Breakdown
Dr. Smith's charge amount for surgery: $300  
Our agreed payment for surgery: - $200  
Balance billing amount $100  
What Sidney Owes
Her out-of-network copayment amount: $150  
The difference between the doctor's charge amount
and what we agreed to pay:
+ $100 (balance billing amount)
Total $250