The article below is from a healthcare attorney we have worked with in the past who specializes in out of network reimbursements. The article highlights how important it is for providers to bill patients for their portion of an out of network claim.


We frequently get calls from out of network providers weekly challenging the premise that balance billing of patients is required for out of network healthcare providers. The reason for these calls is because there is no statute in any state that specifically requires balance billing with just a few exceptions. However, there are literally dozens of cases in federal and state court where health insurers sue out of network healthcare providers for failing to collect coinsurance, deductibles and the balance bill (“Patient Cost Share”) for out of network providers.

A balance bill is simply the difference between an out of network provider’s charge and all payments received and this can be different than what is listed on the explanation of benefits because many health plans process out of network benefits as in-network. Therefore, you cannot always rely on and EOB as reflecting an accurate Patient Cost Share.

Balance bill special investigation audits by health plans against out of network healthcare providers are very common. I attached a recent audit that one of our clients received from Unitedhealthcare Empire Plan. If you carefully read the audit report, United Healthcare and it’s client, the State of New York, clearly said forth their position with respect to waiving Patient Cost Share. When Health plans like Unitedhealthcare determine that an out of network healthcare provider is waiving Patient Cost Share (they usually do this by sending patients questionnaires or contacting them by telephone), audit result. Many times these audits escalate to litigation and seven-figure recoupment demands. If any of you require assistance with respect to special investigation audits or balance billing issues, feel free to contact Thomas J. Force, Esq. at or at (631) 870-4040.