Out-of-Network Surprise Billing: Your Rights and a Dispute Plan That Works

A “surprise” out-of-network bill usually arrives when you did everything a careful patient is supposed to do: you picked an in-network hospital, confirmed coverage, showed up for care, and assumed the clinicians involved were part of the same network. Weeks later, you receive a separate bill from an out-of-network doctor, emergency physician group, anesthesiologist, radiologist, or air ambulance provider—often for thousands of dollars.

Federal law has dramatically reduced this problem for many common scenarios. The No Surprises Act (effective January 1, 2022) created nationwide protections that—when they apply—generally limit you to in-network cost-sharing (your normal deductible, copayment, or coinsurance) and prohibit providers from balance billing you for more. ^[1]

But protections are not universal. Some surprise bills are still legal, and many “illegal” surprise bills keep circulating simply because patients do not know what to request, where to complain, or how to get the claim reprocessed correctly.

This guide explains:

• when surprise out-of-network bills are prohibited,
• what situations still create legal out-of-network charges,
• and a dispute plan you can follow to challenge incorrect charges quickly.

(This is educational information, not legal advice. Rules vary by plan type and state, but the steps below align with federal guidance.)

A surprise out-of-network bill is typically a bill from a provider you did not choose—especially when:

• you received emergency care, or
• you received non-emergency care at an in-network hospital or ambulatory surgical center but were treated by an out-of-network clinician involved in your care.

Federal guidance specifically highlights that surprise billing protections apply to emergency services and to certain non-emergency services delivered at in-network facilities when out-of-network providers are involved. ^[1]

Common surprise-bill sources include:

• emergency department clinicians,
• anesthesiology,
• radiology,
• pathology,
• neonatology,
• assistant surgeons, hospitalists, and intensivists,
• and diagnostic services like lab and imaging—often billed separately. ^[2]

Out-of-network

A provider or facility without a contract with your health plan (or not in your plan’s network).

Balance billing

Charging you the difference between the provider’s full charge and what your plan pays—on top of your deductible/copayment/coinsurance. Federal law prohibits balance billing in many “surprise bill” situations. ^[1]

In-network cost-sharing

What you would normally pay if the care were in-network—your plan’s deductible, copayment, or coinsurance. When the No Surprises Act applies, your cost-sharing cannot be more than the in-network amount for covered services. ^[1]

Explanation of Benefits

A statement from your insurer showing how a claim was processed, what was allowed, what was paid, and what you may owe. This is not the same as a bill—but it is central to disputes.

Federal consumer protections generally apply if you have group health coverage or individual health insurance coverage (many employer plans and marketplace plans). ^[3]

If you receive emergency care, the No Surprises Act generally protects you from being billed more than your in-network cost-sharing—even if:

• the emergency facility is out-of-network, and/or
• the emergency clinicians are out-of-network.

Guidance explains that emergency services must be treated as in-network for patient cost-sharing, and balance billing is prohibited in these situations. ^[1]

Practical meaning: If you went to the emergency room (or had emergency services), and later get an out-of-network bill that asks for more than in-network cost-sharing for covered emergency services, you likely have a strong dispute.

If you schedule care at an in-network hospital, hospital outpatient department, or ambulatory surgical center, you are protected from surprise bills from out-of-network providers who participate in your care as part of that visit. ^[1]

This protection is designed for the classic scenario: you deliberately chose an in-network facility, but you had no realistic ability to choose your anesthesiologist, radiologist, pathologist, or other “facility-based” clinicians.

CMS materials emphasize that surprise bills for non-emergency services are prohibited when provided by out-of-network providers during a patient visit to an in-network facility, and that patient cost-sharing cannot exceed in-network amounts when the law applies. ^[1]

Federal protections extend to many out-of-network air ambulance bills, limiting patients to in-network cost-sharing and prohibiting balance billing in covered scenarios. ^[1]

Knowing the gaps helps you avoid wasting time disputing something that is legally permitted—or helps you shift strategy (for example, using state law protections, negotiating, or appealing medical necessity).

If you choose a facility that is out-of-network for non-emergency care, federal surprise-billing protections generally do not apply. The Department of Labor consumer guidance notes the No Surprises Act protections do not apply to non-emergency services provided by an out-of-network provider at an out-of-network facility. ^[2]

A major and widely discussed gap is ground ambulance billing. Federal law included air ambulance protections, but ground ambulance bills can still create large surprise charges. ^[4]

Some states have passed protections for certain plans, but coverage is uneven and may not apply to self-funded employer plans (which often fall outside state insurance regulation). A Commonwealth Fund review summarizes state approaches to ground ambulance protections. ^[5]

If a service is not covered, surprise-billing protections do not force the plan to cover it. DOL guidance notes you can still be billed for services not covered by your plan. ^[2]

In some non-emergency settings, a provider can ask you to waive protections and agree to be balance billed—but only if strict requirements are met. ^[6]

The most common “I didn’t know I agreed to this” situation is a notice-and-consent form signed shortly before a procedure.

Federal guidance describes a process where, in certain circumstances, a provider or facility can ask you to waive surprise-billing protections for specific non-emergency services—this is called the notice and consent exception. ^[6]

This is crucial: you cannot be asked to waive protections for many common surprise-bill scenarios.

DOL consumer guidance lists multiple categories where notice and consent is not permitted, including:

• emergency services,
• services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology,
• diagnostic services (including radiology and laboratory services),
• services provided by assistant surgeons, hospitalists, and intensivists,
• and certain other circumstances (such as unforeseen urgent medical needs). ^[2]

Mayo Clinic’s patient-facing explanation also states that for several facility-based services (including anesthesia, radiology, pathology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist), providers cannot balance bill and cannot ask you to give up those protections. ^[7]

If you signed a form and later receive a large out-of-network bill:

• request a copy of the signed notice and consent form,
• check whether it was for an allowed category (many are not),
• and check whether it clearly identified the out-of-network provider, estimated charges, and your alternatives.

CMS has detailed guidelines on when the notice-and-consent exception applies and when it doesn’t, and whether the required process was followed. ^[6]

Use this to quickly decide if you likely have a protected surprise-billing case.

• Emergency services where you are billed more than in-network cost-sharing for covered emergency care. ^[1]
• Out-of-network clinicians billing you at an in-network hospital or ambulatory surgical center for services that are part of your visit (especially anesthesia, radiology, pathology, lab, emergency medicine, hospitalist). ^[1]
• Air ambulance surprise bills for covered services. ^[8]

• Non-emergency care at an out-of-network facility. ^[2]
• Ground ambulance bills (unless your state law and plan type protect you). ^[4]
• Services not covered by your plan. ^[2]
• Non-emergency out-of-network services where you gave valid notice and consent (and the category is eligible). ^[6]

If you suspect the bill violates surprise-billing protections, use this process. It’s designed to get your claim reprocessed correctly and stop collections activity while the dispute is pending.

You want:

• the bill from the provider,
• the Explanation of Benefits from your insurer,
• proof the facility was in-network (a screenshot or directory printout helps),
• any consent or estimate documents you signed.

Why it matters: reviewers and billing offices often claim they cannot act without the Explanation of Benefits or claim number.

Write a single-line summary you can repeat to everyone:

• “This was emergency care; I am being billed above my in-network cost-sharing.” ^[3]
• “This was a non-emergency procedure at an in-network hospital; the bill is from an out-of-network anesthesiologist.” ^[1]
• “This was air ambulance; I am being balance billed.” ^[8]

Ask the insurer to:

• confirm whether the No Surprises Act applies to this claim,
• reprocess the claim so your cost-sharing reflects the in-network amount,
• and issue an updated Explanation of Benefits.

If the insurer says the provider can balance bill you, ask: “Is this because the facility was out-of-network, the service was not covered, or because there is a signed notice-and-consent waiver?”

This forces clarity on the specific exception.

Keep it short and specific (you can paste this into a portal message or email).

Sample wording you can use:

“This appears to be a prohibited balance bill under federal surprise-billing protections. The service was [emergency / non-emergency at an in-network facility / air ambulance]. Please stop billing me above in-network cost-sharing and work with my insurer to correct the claim. Please confirm in writing that my account will be placed on hold (no collections) while this is reviewed.” ^[1]

Also request:

• an itemized bill (codes and dates of service),
• the provider’s tax identification number and national provider identifier used for billing,
• and a copy of any notice-and-consent form (if they claim you agreed).

CMS maintains a No Surprises Help Desk and an online complaint process for suspected violations. Federal guidance explains you can contact the Help Desk by phone and submit a complaint through a web-submission process. ^[1] 

This step is especially effective when:

• the provider keeps billing you above in-network amounts,.
• they threaten collections,
• or the insurer refuses to apply protections for an obviously protected scenario.

Because federal protections often do not apply, your strongest tools may be:

• state law protections (if your plan is fully insured and your state has protections), ^[5]
• an internal appeal with your insurer (especially if the transport was medically necessary or ordered by a clinician),
• and negotiation with the ambulance provider (requesting in-network rates, a prompt-pay discount, or charity-care review).

A Washington Post investigation describes how ground ambulance surprise bills can persist even after the No Surprises Act because ground ambulances were excluded, while some states added partial protections that do not necessarily apply to employer-sponsored self-funded plans.^[4]

When you call or write, ask for these three things:

1. “Reprocess this claim under surprise-billing protections and apply in-network cost-sharing.” ^[1]
2. “Send me an updated Explanation of Benefits showing the corrected patient responsibility.”
3. “Confirm the provider is prohibited from balance billing me and that any excess charges should be removed.” ^[1]

If you receive pushback, ask:

• “Does my plan fall under these federal protections for emergency services and out-of-network clinicians at in-network facilities?” ^[2]

Ask the billing office for:

• an itemized bill (line-by-line charges),
• the diagnosis and procedure codes they billed,
• the place of service and facility name,
• and a copy of any notice-and-consent form.

If the provider claims you waived protections, ask them to point to the specific service category and explain why it was eligible for notice and consent. ^[2]

Federal rules require providers and facilities to give uninsured (or self-pay) individuals a good faith estimate of expected charges when scheduling care or upon request. ^[9]

If you later receive a bill that is at least $400 more than the good faith estimate, you may be eligible to dispute the bill through a patient-provider dispute resolution process. ^[9]

This is a different pathway than the out-of-network surprise-billing protections, but it is powerful for self-pay billing disputes.

Mistake 1: Paying the full balance bill “to stop the calls”

If the bill is prohibited, paying can make it harder to unwind, especially if the provider treats it as an accep

Mistake 2: Disputing without the Explanation of Benefits

Your insurer’s Explanation of Benefits shows whether the claim was processed incorrectly (out-of-network when it should be treated as in-network).

Mistake 3: Arguing fairness instead of citing protections

Billing offices respond better to: “This appears prohibited under surprise-billing rules; please reprocess and remove balance billing.”

Mistake 4: Missing the out-of-network facility exception

If you knowingly went to an out-of-network facility for non-emergency care, your dispute strategy should shift toward negotiation, appeal, and state law options. ^[2]

• For planned care without insurance or not using insurance, request a good faith estimate in writing. ^[9]

1. Confirm the scenario (emergency, in-network facility visit, air ambulance, or ground ambulance). ^[1]
2. Get the Explanation of Benefits and compare it to the bill.
3. Ask your insurer to reprocess the claim under surprise-billing protections. ^[5]
4. Put the provider on notice in writing and request a hold on collections.
5. File a complaint through the No Surprises Help Desk if the bill looks prohibited and isn’t corrected. ^[1]
6. If it’s ground ambulance, use state law checks + appeal + negotiation. ^[3]