Balance Billing – Illegal in Colorado

Karen Lee

What is Balance Billing?

Have you or your patients received unexpected healthcare bills even after an insurance company was billed? Have they asked you why they still owe money or what to do about the huge financial burden? In response to recent legislative efforts in the last quarter of 2018 Senator Bennet and others are trying to educate and pass more laws to safeguard patients.

Senator Bennet questions the practice of items like balance billing. Balance billing occurs when a healthcare provider bills a patient for the difference between the provider’s charge and the allowed amount for the service determined by the insurance panel. Consider: the provider charges $90/ hour and the insurance “allows” the charge to be paid at $50/ hour (in-network). The provider would then bill the patient for the $40 difference in price. While the practice is not common, patients and other healthcare providers are seeing this occur more and more in an effort to recoup costs.

In many states Balance Billing still remains legal, but for the state of Colorado according to measure C.R.S. § 10-16-705(3) balance billing is illegal. This is only prohibited when an insured patient obtains treatment from a participating (in-network) provider.

For providers who are unsure if balance billing is legal or not, it is generally illegal if:

  • The patient has Medicare coverage, and is seeing a provider that accepts Medicare
  • The patient has Medicaid coverage, and is seeing a provider that has an agreement with Medicaid

Balance billing doesn’t happen with Medicaid and Medicare providers for the sole reason that providers could lose their contract, face fines, suffer severe penalties, and even face criminal charges in some cases. However, there is less regulation and so the practice is becoming more common with commercial lines of insurance.

To date, the states that have measures against balance billing include: California, Texas, New York, Illinois, Florida, Connecticut, Maryland, Colorado, Minnesota, West Virginia, and Utah. To read more about Senator Bennet’s effort to protect patients, visit:

Are you a provider in the Colorado area and not sure if you are following current insurance guidelines and laws? Ponderosa Billing Service, Inc can help you navigate the complexity of the world of insurance. Contact us today to learn more!

Call 800-452-9282 or e-mail