What does balance billing entail?

Balance billing refers to the practice of billing patients for the difference between what their insurance pays and the total charges incurred for medical services. This commonly occurs when a healthcare provider charges more than what is deemed acceptable by the insurance company.

When it comes to Medicare, balance billing can occur if a provider is not a participating provider in the Medicare program and decides to bill the patient for the difference after Medicare has paid its portion. This often includes any charges that exceed the amounts outlined in the Medicare fee schedule, which establishes the maximum amount that can be charged for services. Therefore, billing patients for charges that exceed this fee schedule fits the definition of balance billing, making it the correct choice in this context.

The other options do not accurately reflect the concept of balance billing. Billing patients for the total amount charged does not necessarily involve the difference between insurance payments and the total charge; it simply indicates the total bill without specific context regarding insurance payments. Basing patient bills on insurance agreements references the concept of in-network billing, where providers agree not to charge patients above contracted rates. Charging a flat fee for all services implies a set price regardless of insurance considerations and does not take into account the nuances of balance billing that typically relates to differing fees and insurance reimbursements.