Get the facts: What is in-network vs. out-of-network? And why did I get a bill from an out-of-network doctor?

• Bills from out-of-network doctors can be shockingly high, so it almost always makes more sense to explore your in-network options and find a suitable alternative.
• Regardless of whether you chose to schedule an appointment with an out-of-network doctor or received care from one during a hospital stay without your knowledge, it’s important to understand your rights, your options and the steps you should take if you find yourself struggling to pay the bill.
• The No Surprises Act protects people who unknowingly receive care from an out-of-network provider while being treated at an in-network hospital.
• The No Surprises Act does not apply to ground ambulances, meaning companies that operate ambulance services are still legally allowed to bill patients for rides to the hospital, even if the patient is experiencing a medical emergency. 

You’ve probably heard it’s important to choose a doctor or hospital that’s part of your health plan’s network, but nothing brings that reality into focus faster than opening your mail and seeing a bill you didn’t expect.

Regardless of whether you chose to schedule an appointment with an out-of-network doctor or received care from one during a hospital stay without your knowledge, the resulting bill is stressful to deal with. And for many people, it can mean difficult choices about how to pay the bill while trying to manage everyday expenses. That’s why it’s important to understand your rights, your options and the steps you should take if you find yourself in this situation.

The provider you saw does not have a contract with your health insurer, meaning they have not agreed to negotiated payment rates with your insurer. As a result, your insurer either:

• Paid them an out-of-network rate, and the provider, in turn, is now billing you for the balance they feel is owed to them; or,
• Paid them nothing if your plan doesn’t have out-of-network benefits. In that case, the provider can bill you for the full amount of the service only if you signed a consent form in advance. 

It’s possible you could get some support with resolving the bill.

• If you get your insurance through work, you may be eligible for a program that’s designed to help employees facing large bills from out-of-network providers. For example, some employers have opted into a UnitedHealthcare program that negotiates with out-of-network providers on members’ behalf – helping reduce what they owe to make the bill more manageable.  
• So as a first step, check with your health plan to confirm if this type of support is available to you.
• If you don’t have access to that kind of support program, call the provider’s office to inquire about payment plan options. Your provider may allow you to make monthly payments against your bill until it’s paid off.

To avoid this scenario in the future, always confirm that the provider you’re planning to see participates in your insurer’s network. Bills from out-of-network doctors can be shockingly high, so it almost always makes more sense to explore your in-network options and find a suitable alternative. At UnitedHealthcare, we want to make it as easy as possible for our members to get the care they need close to home, so we’ve developed one of the largest care provider networks in the country – more than 1.7 million physicians and care professionals and over 7,000 hospitals and care facilities nationwide.¹

When you need to schedule a doctor appointment or prepare for a surgery or procedure, your first step should always be to check out the providers section of your insurer’s member portal or mobile app. You can also give your insurer a call at the number on your health plan ID card if you have questions or need support.

This situation happens more often than you might think. The good news is, you won’t be responsible for paying the bill, thanks to a law called the No Surprises Act.

Congress passed this law to protect people who unknowingly receive care from an out-of-network provider while being treated at an in-network hospital.  

• Many hospitals contract with physician groups to staff their ERs or provide services such as anesthesia and radiology.
• Unfortunately, those physician groups don’t always have contracts with the health insurers that the hospitals themselves have established contracts with. This means you could choose an in-network surgeon and have your surgery at an in-network hospital but receive anesthesia from an out-of-network anesthesiologist.
• In the past, those out-of-network physician groups would often bill their patients for the care they provided, even though those patients had no way of knowing the physicians caring for them were out of network. That’s where the term “surprise bills” came from.
• The No Surprises Act was passed in 2020 in large part because of these billing practices. The law prohibits out-of-network providers from billing patients in these situations for anything more than the cost-share owed under their benefit plan, meaning their copay, coinsurance or deductible.

If you think you’ve received a surprise bill, give your health plan a call. They can confirm whether the care you received makes you eligible for protection through the No Surprises Act. If you’re eligible, you will not be responsible for paying anything more than your cost-share.  

The No Surprises Act has protected patients from surprise bills since it went into effect in 2022, but unfortunately, it does not apply to ground ambulances.

• The members of Congress who wrote the law opted to carve out ground ambulances.
• This means companies that operate ambulance services are still legally allowed to send surprise bills to the people they transport to the hospital, even if the patient is experiencing a medical emergency.
• Unfortunately, this creates an incentive for companies that operate ambulances to avoid establishing contracts with health insurers that would bring them into the insurers’ networks, for the simple reason that they can make more money by staying out of network and sending surprise bills to their patients.
• In many cases, these companies’ charges are three to four times higher than the Medicare rate for an ambulance ride. If they were to join insurers’ networks, the in-network payment rate would typically be closer to the Medicare rate, and they would lose the ability to bill patients for anything beyond the copay or coinsurance owed under their benefit plan.

This carve-out is unfortunate as it leaves people on the hook for paying steep bills for a service they received during one of the scariest and most vulnerable moments of their lives. And those bills typically come as a shock, ranging anywhere from a few hundred to several thousand dollars.

• During a medical emergency, most people would not think to ask the 911 operator if the ambulance that’s being sent to their home is in their health plan’s network.
• The priority is getting to the hospital as quickly and safely as possible.
• For such an important and potentially life-saving service, it’s reasonable to assume it would be covered by your insurance.

If you’re facing one of these bills, consider these tips:

• Check if you live in one of the 24 states that have passed legislation to protect their residents from surprise ambulance bills. This map from The Commonwealth Fund shows the states where these protections are in place. If you’re enrolled in a fully insured employer-sponsored plan and live in one of these states, you should be protected from having to pay the bill. That’s because fully insured plans are governed by state laws.
• It’s important to note, however, that most people who get their insurance through work are enrolled in a self-insured plan, and those plans are subject to federal rather than state laws. If you’re not sure what type of plan you’re enrolled in, check with your company’s HR department.
• If you’re enrolled in a self-insured employer-sponsored plan, reach out to your health plan to ask for support. It’s possible your insurer will be able to negotiate a lower payment even though it doesn’t have a contract with the company that operates the ambulance.
• You can also contact the ambulance operator and ask if they’d be willing to accept a lower payment or allow you to spread out your payments through a monthly payment plan.

Your health is most important, so in a true medical emergency, never hesitate to call 911 and accept an ambulance ride to the hospital. And it’s always best to go to the nearest hospital in a true emergency situation. Even if the hospital isn’t in your plan’s network, your care will still be processed at the in-network rate.

Understanding healthcare bills is not easy, and that’s especially true when the providers sending those bills don’t participate in your health plan’s network. That’s one of the reasons why staying in your plan’s network is one of the most effective ways to avoid unexpected bills and keep your healthcare more affordable. This article provides more information and tips to help you navigate your plan’s network.