A “surprise medical bill” is a bill a patient receives from a health care provider that is 1) outside of their insurance network and 2) in a circumstance that is outside of the patient’s control. In these circumstances, the health care provider might send a bill to the patient for the “balance” that remains after: 1) an insurer makes a payment; and 2) the patient’s deductible and any copay or coinsurance is applied.
A patient might receive a surprise bill during a medical emergency, such as when a patient is taken to an “out-of-network” hospital during an emergency or when the emergency room doctor is out-of-network even if the hospital is in-network. Patients have also received surprise bills during a scheduled medical procedure at an “in-network” facility with an “in-network” surgeon, but where another provider (such as an anesthesiologist, radiologist, or medical lab) is out-of-network. “Surprise medical bill” and “balance bill” are often used interchangeably.