Balance billing: what providers can and can't bill in 2026

Where balance billing is prohibited

• Emergency services, including post-stabilization care, at any facility.
• Out-of-network services at in-network facilities: anesthesia, radiology, pathology, neonatology, assistant surgery, hospitalist and intensivist services, plus other services unless valid notice and consent was obtained.
• Out-of-network air ambulance transport.

In those situations the patient owes only in-network cost sharing — deductible, copay, coinsurance — calculated as if the care had been in network. That amount counts toward their in-network out-of-pocket maximum.

What you can still bill

• Cost sharing at in-network levels, which you must collect.
• Non-covered services the patient chose knowingly, where consent was validly obtained and the service isn't on the no-waiver list.
• Self-pay and uninsured patients — subject to the good faith estimate requirements.

The other half: recovering the difference

Losing the ability to balance bill doesn't mean accepting the plan's number. When the plan's payment is below what the service is worth, the IDR process exists to reprice it. Providers have prevailed in roughly 88% of federal determinations. What kills claims is not weak merits — it's blown deadlines and eligibility errors.

State balance billing laws still matter

Twenty-two states have their own protections, most covering only state-regulated plans. Some use a payment standard, some arbitration, some both. Which forum your claim belongs in depends on the plan behind it, not the state you practiced in. See IDR by state.

A working checklist

• Flag every claim where the patient can't be balance billed, at the point of coding
• Collect in-network cost sharing only, and document the calculation
• Never use notice and consent for an ancillary service
• Route every underpaid remit into an eligibility screen rather than a write-off queue