OUT OF NETWORK
What does “out of network” mean on an EOB — and can they bill me the difference?
“Out of network” means the provider has no contract with your health plan, so the plan may pay less and the provider may bill you for the difference between its charge and the plan’s allowed amount — called balance billing. The federal No Surprises Act, in effect since January 1, 2022, protects most insured people from surprise out-of-network bills for emergency care and some other situations.
Why it’s confusing
You often don’t choose the provider who turns out to be out of network: an emergency department doctor, an anesthesiologist at an in-network hospital, or an air ambulance. The EOB is where you first find out.
The EOB may also show a lower plan payment and a larger “you may owe”, without saying whether federal protections apply.
How to read it
Check the network status on the EOB line. Some EOBs mark it plainly; others show it through a different coinsurance rate or a remark code.
Check whether the care is one of the situations the No Surprises Act covers. According to CMS, it protects you from unexpected out-of-network bills for emergency room visits; non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center; and air ambulance services.
If the bill is higher than your in-network share would have been in one of those situations, contact the provider and your insurer, and you can contact the No Surprises Help Desk run by CMS on 1-800-985-3059.
What it does not mean
- That every out-of-network bill is illegal. Outside the protected situations, balance billing may be allowed.
- That “in-network hospital” means every clinician there was in network. That is exactly the gap the law addresses for some services.
- That you must pay before asking questions. Ask first, especially if you think the protections apply.
Where you’ll see it
- Insurance EOBs, on the line for the out-of-network provider.
- Bills from emergency physicians, anesthesia groups, labs or air ambulance companies.
Questions worth asking
Ask your insurer
- Was this provider out of network, and how was the payment worked out?
- Do No Surprises Act protections apply to this claim?
Ask the provider
- Why are you billing more than my in-network share?
- Is this care covered by surprise billing protections?
Got an out-of-network charge you didn’t expect? Attach the EOB or bill, and Clariti will explain what it says.
Common questions
- What is balance billing?
- When a provider bills you for the difference between its charge and your plan’s allowed amount. HealthCare.gov notes a preferred (in-network) provider may not balance-bill you for covered services.
- What does the No Surprises Act cover?
- CMS says it protects you from unexpected out-of-network bills for emergency room visits, some non-emergency care linked to in-network facilities, and air ambulance services.
- Who can I call about a surprise bill?
- CMS runs a help line for questions and complaints about the No Surprises Act: 1-800-985-3059.