You went to an in-network hospital but got an out-of-network bill
Why does this happen at an in-network hospital?
A hospital contracting with your insurer does not mean every clinician working inside it does. Anesthesiologists, radiologists, pathologists and assistant surgeons often belong to independent groups with their own insurer contracts. You usually do not choose them, and you may never meet them, yet each one can send its own bill.
If the group is outside your plan's network, the insurer may pay less than the group charged, and the group may bill you for the difference. That difference is what is commonly called balance billing.
What does the No Surprises Act say about this?
For people with most private health plans, including employer and marketplace plans, the No Surprises Act protects against balance billing by out-of-network providers at in-network facilities for non-emergency services, unless the patient gave proper notice and consent under the law (42 U.S.C. § 300gg-112). Anesthesiology, radiology, pathology and assistant surgeons at an in-network hospital are typical examples.
The law does not cover Medicare, Medicaid, TRICARE, VA or Indian Health Service coverage. Those programs have their own billing rules.
How do you check whether the bill is allowed?
Start with paperwork you already have, and look for what you actually agreed to before the procedure.
- Your EOB, to see how the insurer processed the claim and what it lists as your responsibility.
- Any consent or notice form you signed before treatment. Ask the provider for a copy if you do not have one.
- The name and network status of the billing group, which may differ from the hospital's.
- Whether the amount billed to you is more than your plan's normal in-network cost sharing.
- The date of service, to confirm the bill matches the visit.
What should you do first?
Do not pay the full amount right away, and do not ignore the bill. Call your insurer, tell them an out-of-network provider treated you at an in-network facility, and ask whether the claim was processed under the correct rules. Insurers can sometimes reprocess a claim at in-network cost sharing.
Then contact the provider's billing office. Ask them to confirm in writing whether they are billing you under the No Surprises Act, to send a copy of any signed consent, and to hold the account while it is reviewed.
Where can you escalate if it is not resolved?
You can call the CMS No Surprises Help Desk at 1-800-985-3059 or visit cms.gov/nosurprises for information about how to submit a complaint. Complaints about how your insurer handled the claim can go to your state insurance department, and complaints about provider billing practices may go to your state attorney general.
In a written dispute, state the date of service, the provider, the amount, and that you are asking for the bill to be corrected under the No Surprises Act. Medical Bill Dispute Pro's letter includes a section on applicable regulations and a 10-business-day response request, and you should review it before sending.
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Frequently asked questions
Can an out-of-network anesthesiologist bill me at an in-network hospital?
For non-emergency care, federal law generally prohibits balance billing in this situation unless you received proper notice and gave consent. If you did not sign anything, or if the bill is higher than your plan's in-network cost sharing, ask the provider and your insurer to review it before paying.
What if I signed a consent form before the procedure?
A signed form may allow out-of-network billing only if it met the law's notice-and-consent requirements. Ask for a copy and read it. Consent buried in a stack of admission paperwork, or signed without a clear explanation of costs, is worth questioning with the provider and your state regulator.
Does this apply if my surgery was an emergency?
Emergency care is covered by a related provision of the No Surprises Act, which protects insured patients from balance billing by out-of-network emergency providers and facilities and generally limits cost sharing to in-network levels. Either way, compare your bill with your EOB and ask for an itemized statement.
Who do I call first, the insurer or the provider?
Many people call the insurer first to confirm how the claim was processed, then the provider to ask for a hold and an itemized bill. Either order works. Write down names, dates and reference numbers, because you may need them if you escalate the dispute.
What if I have Medicare or Medicaid?
The federal No Surprises Act does not cover those programs, but they have their own billing limits. Providers who accept Medicaid generally may not bill you beyond the Medicaid payment and any allowed copay. Check your Medicare Summary Notice or contact your state Medicaid agency.
Sources and further reading
- 42 U.S.C. § 300gg-112 (out-of-network providers at in-network facilities)
- CMS: No Surprises Act
- CMS: Medical bill rights
Related guides
Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.