When In-Network Becomes Out-of-Network

You did your homework. You chose a hospital and surgeon who both accept your insurance, so the final bill should be predictable.

Then suddenly a statement arrives from a provider you never picked, asking for hundreds or even thousands of dollars. This is called surprise billing, and it catches many well-prepared patients off guard.

How an In-Network Visit Turns Out-of-Network

Every health plan has a network of doctors and facilities that agree to discounted rates. A provider outside that network can charge full price, and your plan may cover little or none of it.

The complication is that you do not always choose who provides medical treatment for you. At an in-network hospital, the anesthesiologist, radiologist, or lab may belong to an independent group that has no contract with your plan. That group can then send you the difference between what it charges and what your insurer paid, which is known as balance billing.

Before federal protections, research found that among large group plan members, roughly one in five emergency room visits and one in six in-network hospital admissions led to a surprise bill.

What the No Surprises Act Changed

The federal No Surprises Act took effect on January 1, 2022, and prohibits balance billing for specific out-of-network services. It covers emergency care, even at an out-of-network hospital, and certain out-of-network services provided at in-network hospitals and surgery centers, such as anesthesia.

It also covers out-of-network air ambulance flights. In these situations, you should owe only your usual in-network deductible, copay, or coinsurance, and the provider and insurer settle the remainder between themselves.

Where Gaps Still Exist

The biggest gap is ground ambulances. The law does not cover them, and KFF found that about half of emergency ground ambulance rides for privately insured patients result in an out-of-network charge.

A second gap involves consent. Some out-of-network providers may ask you to sign a form giving up your protections, and if you sign, you could be responsible for the bill. Finally, the law does not protect you when you knowingly choose an out-of-network provider for non-emergency care. Some states add their own protections, so the rules can vary depending on where you live.

How to Protect Yourself

Before planned care, ask whether every provider involved, including anesthesia and lab services, is in your network. Request a written estimate of costs whenever possible. Review each explanation of benefits from your insurer, and question any bill that does not match it. If you are unsure whether a charge is allowed, you can dispute it with your insurer or the provider.

If you would like help understanding your network or reviewing your health coverage, contact our office today.