Introduction: Why Compliance Matters in 2025
Healthcare providers face increasing scrutiny over billing practices and cost-sharing policies.
Improper balance billing and waivers of copays and deductibles can trigger civil and criminal penalties under the False Claims Act (FCA) and lead to exclusion from Medicare and Medicaid.
Additionally, the ongoing implementation of the No Surprises Act (NSA) and recent HHS OIG compliance guidance (Nov 2023) have reshaped the regulatory landscape, demanding a proactive approach to compliance.
What Is Balance Billing and Why It Matters
Balance billing is the practice of charging a patient the difference between the provider’s billed amount and what the insurer pays.
✅ When Balance Billing Is Permissible
- In certain out-of-network scenarios where patients consent in writing to pay the additional amount.
- For services not covered by insurance, with full prior disclosure.
❌ When Balance Billing Is Prohibited
- For emergency services, even if provided by an out-of-network provider.
- For many non-emergency services at in-network facilities, as restricted by the NSA.
The American Medical Association (AMA) emphasizes the need for transparent billing practices that protect patients and comply with state and federal rules.
Copay and Deductible Waivers: A Hidden Compliance Risk
Providers who routinely waive patient copays or deductibles may be seen as offering improper inducements. This can violate:
- The Anti-Kickback Statute (AKS)
- The False Claims Act (FCA)
⚠️ Consequences of Improper Waivers
- Civil penalties and treble damages under the FCA
- Potential exclusion from Medicare and Medicaid
- Heightened scrutiny from federal regulators
The HHS OIG Compliance Guidance (Nov 2023) warns providers to establish internal safeguards to detect and prevent such practices.
False Claims Act Liability: A Critical Compliance Focus
The FCA penalizes anyone who knowingly submits false or fraudulent claims for payment to the federal government.
💡 FCA Exposure in Billing
- Submitting claims that do not comply with federal billing laws
- Misrepresenting eligibility or cost-sharing arrangements
- Failing to refund overpayments or report improper billing
Penalties under the FCA:
- Treble damages
- Civil fines per false claim
- Risk of being barred from participating in federal health programs
The No Surprises Act (NSA): Protecting Patients and Providers
Enacted as part of the Consolidated Appropriations Act of 2021, the NSA took effect on January 1, 2022, significantly altering billing rules.
⭐ Key NSA Provisions
- Prohibits balance billing for most emergency services
- Requires advance cost estimates and disclosures for non-emergency services
- Introduces an Independent Dispute Resolution (IDR) process for payment disagreements between providers and insurers
⚖️ Recent NSA Updates
- Ongoing litigation and regulatory updates have shaped how IDR is conducted
- Providers must keep up with new proposed rules and court decisions to avoid compliance gaps
Practical Compliance Steps for Healthcare Providers
To reduce legal, financial, and reputational risks, healthcare providers should:
- Educate Staff Regularly
Provide training on billing rules, cost-sharing obligations, and NSA requirements. - Update Policies and Procedures
Include clear processes for obtaining patient consent, billing disclosures, and IDR participation. - Monitor and Audit Billing Practices
Conduct periodic reviews to ensure alignment with FCA, OIG guidance, and NSA requirements. - Strengthen Documentation
Keep accurate records of patient agreements, disclosures, and communications. - Respond to Issues Promptly
Investigate and correct errors quickly to avoid escalated penalties.
Key Takeaways for 2025
- Know when balance billing is prohibited under state and federal law.
- Avoid routine waivers of copays/deductibles to reduce FCA exposure.
- Stay informed on HHS OIG guidance and NSA IDR updates.
- Build a strong compliance program that emphasizes education, monitoring, and transparency.
Conclusion: Staying Ahead of Compliance Risks
The interplay between balance billing laws, False Claims Act enforcement, and the No Surprises Act marks a new era of accountability in healthcare.
Providers who invest in robust compliance frameworks not only protect themselves from costly penalties but also strengthen patient trust and ensure sustainable participation in both government and private insurance programs.