Can a doctor be in-network but the hospital out-of-network?

Yes, and vice versa. Network status applies separately to each provider and facility. Always verify both the doctor and the facility are in your plan's network before a procedure.

What is balance billing?

Balance billing is when an out-of-network provider bills you for the difference between their charge and what your insurance paid. The No Surprises Act prohibits balance billing in emergency situations and for certain non-emergency services at in-network facilities.

In-Network vs. Out-of-Network: How It Changes What You Pay

What In-Network and Out-of-Network Mean

In-network providers have signed contracts with your insurance company agreeing to accept negotiated rates for their services. Out-of-network providers have no such agreement and can charge any amount they choose. When you see an in-network provider, your insurer pays its contracted rate and you pay your standard copay or coinsurance. When you see an out-of-network provider, you may face a separate deductible, higher coinsurance (often 40-50%), and possible balance billing.

The Cost Difference Can Be Enormous

A procedure that costs you $500 in-network might cost $3,000 or more out-of-network. This is because out-of-network providers can charge list prices rather than negotiated rates, your out-of-network deductible is typically 2-3 times higher, your coinsurance rate is higher, and some plans have no out-of-network coverage at all (HMO plans). The single most impactful thing you can do to control medical costs is to verify network status before every visit.

How to Verify Network Status

Before scheduling, call your insurance company and ask: 'Is Dr. [name] at [facility] in my plan's network?' Do not rely solely on the provider's website or office staff — they may not know your specific plan's network. Get a reference number for the call. Also verify that the facility, not just the doctor, is in-network. It is possible for a doctor to be in-network at one hospital but out-of-network at another.

No Surprises Act Protections

The No Surprises Act, effective since January 2022, protects you from balance billing in specific scenarios: emergency services at any facility, non-emergency services at an in-network facility from an out-of-network provider you did not choose (like an anesthesiologist or radiologist), and air ambulance services. In these situations, you only pay in-network cost-sharing rates regardless of the provider's network status.

What to Do If You Get an Out-of-Network Bill

First, check if the No Surprises Act applies to your situation. If it does, you should only owe in-network rates — contact your insurer and the provider to correct the bill. If it does not apply, call the provider and ask about in-network rates or a self-pay discount. Many providers will reduce their charges when asked. You can also submit the bill to your insurance for out-of-network reimbursement, even if the amount paid is lower than the total.