Above the contracted rate
Can an in-network provider bill me for the difference between their charge and what insurance paid?
A provider charges $400. Your plan's allowed amount is $150. The plan pays $120 and says you owe $30. Then the bill arrives asking for $280.
That gap — the difference between the list price and the contracted rate — is the contractual adjustment, and for an in-network provider it is supposed to be written off. Charging it to you instead is called balance billing.
Why the write-off exists
A provider's list price is largely notional. Almost nobody pays it. When a provider joins a plan's network they agree to accept the plan's allowed amount as payment in full, in exchange for being listed as in-network and getting the patient volume that comes with it.
The write-off is the price of that deal. It is not a discount the provider is doing you a favour by applying.
How to check it yourself
On the Explanation of Benefits, find the line for that service and three numbers:
- Allowed amount — the contracted rate
- Plan paid — what your insurer sent them
- Patient responsibility — your share
For an in-network provider, allowed minus plan paid is the most they should be collecting from you. If the bill asks for more than that, ask why.
The gross charge on the bill is almost always higher than the allowed amount. That by itself is normal and is not the problem — the question is only whether the adjustment was applied before the balance was struck.
What to ask
Please apply the contractual adjustment for [service] and rebill at [allowed minus plan paid], the allowed amount less the plan's payment.
When it is allowed
Balance billing is generally permitted when the provider is out of network and you were not in an emergency and were properly informed in advance. If you chose an out-of-network provider knowingly, the contracted-rate logic does not apply, because there is no contract.
Two large exceptions where it is not allowed even out of network:
- Emergency care. Federal law limits your cost sharing to the in-network amount, and that protection cannot be waived by a form you sign at registration.
- Out-of-network providers at an in-network facility. The anaesthesiologist, radiologist or pathologist you never chose. Same protection.
If the provider disagrees
Call your plan. An in-network provider billing above the allowed amount is a violation of their contract with the insurer, and the insurer is the counterparty to that contract. They can apply pressure you cannot.
Ask the plan to note the call, and ask for a reference number.
This is general information, not legal, medical or financial advice, and not a statement about your particular bill. A difference between two documents often has an ordinary explanation, and the billing office is the one who can give it.