Avoiding Balance Billing and the Waiving Copays and Deductibles Liability

Healthcare billing has always been a source of confusion and frustration for both patients and providers. One of the most pressing issues today is Balance Billing—a practice that can leave patients with unexpected expenses and providers exposed to compliance risks. Add in the growing scrutiny over waiving copays and deductibles, and the landscape becomes even more complex.

In this blog, we’ll break down what balance billing really means, why it matters more than ever in the age of the No Surprises Act, and how healthcare providers can safeguard themselves from liability while still supporting patients who are struggling with costs.

What Is Balance Billing and Why It Matters

Before diving into strategies and rules, let’s start with the basics: what is balance billing?

Balance billing happens when a provider bills the patient for the difference between what the insurance pays and the total charges for a service. For example, if your charge is $1,000 and insurance covers $600, billing the patient for the remaining $400 is balance billing.

Sounds straightforward? The problem is—it isn’t always legal. Laws like the No Surprises Act now limit or outright ban balance billing in many scenarios, particularly when patients have no control over the network status of the provider, such as emergency situations.

For providers, this isn’t just about compliance. It’s about trust. Patients who feel blindsided by unexpected bills may lose confidence in your practice, leading to reputational harm that no revenue can repair.

The Risk of Waiving Copays and Deductibles

It can seem helpful to waive patient copays or deductibles in an instance of someone needing assistance but it can be very risky. Regulators view routine waiving of copays and deductibles as a form of inducement and may label it Medical Fraud. 

Copays and deductibles are in place for a reason, to ensure patients are paying for their care, and repeatedly waiving them can be problematic. Not only can this put you at odds with provider compliance rules, but often cases for somehow in your billing practice that insurers or regulators will not miss.

The Role of the No Surprises Act

The No Surprises Act has brought balance billing into sharp focus by banning it in emergency care and certain out-of-network scenarios. Providers can no longer charge patients beyond the in-network cost-sharing amount in many cases.

This means that what used to be a “gray area” for many organizations is now governed by clear law. Violations can lead to financial penalties, legal liability, and significant damage to your professional reputation.

For providers, understanding these rules is not optional—it’s mandatory. Compliance with the No Surprises Act is not only about avoiding penalties, but also about ensuring fairness and transparency in patient care.

Patient Trust and Financial Transparency

Financial concerns are the primary reason individuals postpone or do not pursue medical care. Medical bill assistance comes into play here. By simply providing upfront, clear cost estimates, payment plans or assistance programs for patients can alleviate financial stress without running afoul of compliance requirements.

Patients are more likely to stay loyal to providers who are transparent about costs and billing practices. In today's world of online reviews, trust regarding finances can be as important as trust in clinical care.

Avoiding Compliance Pitfalls

How can providers navigate these challenges without crossing compliance lines? Here are some strategies:

1. Train Staff Frequently – Ensure that both billing and front-community teams are educated on balance billing regulations, rules, and waivers.
2. Implement Standardized Policies – Create written office policies for copays, deductibles, and billing disputes.
3. Provide Authentic Financial Assistance Programs – Rather than waiving charges, help people apply for hardship programs.
4. Conduct Routine Audits – Regular audits will help you stay compliant with provider guidelines.
5. Be Up Front With Patients – Based on your protocol and for services rendered, inform patients of their financial responsibility before the service. 

Balance Billing in Real Life: A Scenario

Consider the following: A patient comes into your ER after a collision; the patient has no choice but to see an out-of-network provider. Under the No Surprises Act, you cannot chart a bill for more than the in-network rate. If you do, you risk taking legal action against you.

Now consider the situation where the patient is unable to afford their copay. Waiving the copay without documentation may seem nice, but it could be reported as medical fraud. Instead, directing the patient towards a hardship program or establishing a payment plan will still ensure compliance with financial and legal standards and provide needed assistance to the patient.

This is the delicate balancing act that a provider faces daily: caring for patients, and ensuring financial and legal wellbeing.

Why Balance Billing Isn’t Just About Money

At its core, balance billing is more than a financial transaction. It represents a manifestation of how much we value fairness, accountability, and patient trust in the healthcare system. When providers avoid erroneous billing and emphasize compliance, they not only protect themselves, but they also strengthen relationships with patients.

When patients understand, the provider is committed to transparency, they are more likely to stay, refer, and trust their care availability by that provider, regardless of cost.

Conclusion: The Road Ahead: Compliance as a Competitive Edge

In today’s environment, provider compliance isn't only a regulatory requirement–it’s a competitive edge. The organizations that genuinely commit to billing transparency will be more likely to win the trust of patients and avoid costly penalties.

Consider compliance as more than a protective shield–it can be a growth strategy. With increased regulations and awareness, the winners will be those providers that center compliance and patient trust at the heart of their organizations.