Why is the billed amount higher than what my plan paid?

The billed amount is the provider’s own charge, and your plan pays only its allowed amount. In network, the provider agreed to that price and may not bill you the difference. The No Surprises Act gives you the same result in an emergency at any ER, in network or not, and when an out-of-network clinician treats you at an in-network hospital or surgery center: you owe only your in-network share, generally figured on the plan’s qualifying payment amount (QPA) under the federal law, or on the amount a state’s own law sets where that law applies, and the provider may not bill you the rest (42 U.S.C. §§ 300gg-111, 300gg-131 and 300gg-132; 45 CFR 149.110, 149.120, 149.410 and 149.420).

Under the federal law, that share at the ER can be less than Medicare’s own rate. Provern measured it from public data alone: in CMS’s federal dispute data for 2023 to 2025, on the kinds of ER visit that make up 99.6% of the disputed ER visits, a patient’s share at 20% coinsurance came to 31% to 45% of Medicare’s 2026 rate for the same visit, in 160 of 163 comparisons state by state, once the deductible is met (before it is, you pay the QPA itself, which is above Medicare’s rate).

A balance bill can still come for planned care you chose from an out-of-network provider outside these protections, or agreed to in a valid consent signed in advance.

What is an allowed amount? — answered from the law, on provern.org