Fighting Out-of-Network Denials

An out-of-network (OON) denial occurs when you receive care from a provider or facility that does not have a contract with your insurance company. These can be some of the most expensive and confusing denials, but new federal laws provide significant protection for patients.

The No Surprises Act: Your Strongest Protection

The No Surprises Act, which took effect in 2022, is a federal law that protects consumers from most "surprise" medical bills. A surprise bill happens when you receive unexpected bills from OON providers you did not choose.

The law protects you in these common situations:

  • Emergency Services: If you receive care at an OON emergency room, the hospital and doctors can't bill you for more than your plan's in-network cost-sharing amounts. This applies even if you could have chosen an in-network hospital.
  • Non-Emergency Services at In-Network Facilities: If you have a procedure at an in-network hospital or facility, but are unknowingly treated by an OON provider (like an anesthesiologist, pathologist, or radiologist), they are not allowed to balance bill you.

Balance billing is when a provider bills you for the difference between what they charged and what your insurer paid. The No Surprises Act makes balance billing illegal in the situations described above.

How to Appeal an OON Denial

If you receive a denial or a bill that you believe violates the No Surprises Act, your appeal should focus on your rights under the law.

  1. Identify the Situation: Determine if your case falls under the surprise billing protections. Was it an emergency visit? Were you at an in-network facility?
  2. Cite the No Surprises Act: In your appeal letter to your insurer and any communication with the provider, explicitly state that you believe this is a violation of the No Surprises Act. Use phrases like, "This bill for out-of-network services at an in-network facility constitutes balance billing, which is prohibited by the No Surprises Act."
  3. Demand In-Network Rates: Your appeal should demand that the claim be re-processed at your plan's in-network rates and that you should only be responsible for your in-network deductible, copay, or coinsurance.
  4. File a Complaint: If the provider or insurer won't budge, you can file a complaint with the federal government through the No Surprises Help Desk.

When Protections May Not Apply

The No Surprises Act does not apply to all situations. For example, it generally does not cover non-emergency services if you knowingly chose an OON provider when an in-network option was available. It also does not apply to ground ambulance services. In these cases, your appeal might need to focus on other arguments, such as a lack of available in-network specialists in your area.