Out-of-Network Care & Balance Billing (No Surprises Act)

Taking the stress out of surprise bills

Understanding insurance can be challenging, particularly with terms like “out-of-network” and “balance billing.” This page clarifies the meanings of these terms, outlines how recent federal laws protect you from unexpected bills, and explains how our team collaborates with you to reduce billing surprises. Our goal is to allow you to concentrate on healing rather than dealing with paperwork.

Important: This page is for general education and does not replace advice from your health plan, employer, or attorney. Your specific coverage will depend on your policy and the laws of your state.

In-Network vs. Out-Of-Network

In-network providers and facilities have a contract with your health plan. They agree on negotiated rates, and your share of the cost is usually limited to your plan’s in-network copayments, coinsurance, and deductible.
Out-of-network (OON) providers and facilities do not have a contract with your health plan. The plan may pay a portion of the bill based on its “out-of-network” benefit, and you are often responsible for a larger share.

In the past, patients sometimes received unexpected bills after receiving care from out-of-network providers, often without their knowledge. This commonly occurred in emergencies or during hospital stays when some specialists were out-of-network.

What is “Balance Billing”?

When an out-of-network provider sends you a bill for the difference between what the provider charges and what your health plan pays, that difference is called balance billing.

For example, if the provider charges $1,000:

Your plan pays $600
Your in-network cost for that service would normally be $150
The provider might bill you the unpaid balance in an out-of-network situation

Balance bills can be significantly higher than in-network costs and may not count toward your annual out-of-pocket maximum.

How the No Surprises Act Protects You

The federal No Surprises Act provides patients with essential protections against certain types of unexpected out-of-network bills. In general, if you are covered by a group or individual health plan,

Most emergency services, including care at an out-of-network emergency department or hospital
Non-emergency services from out-of-network providers at in-network facilities (such as hospital-based anesthesiologists, radiologists, pathologists, and others)
Out-of-network air ambulance services

In these protected situations:

You cannot be balance billed by those providers
You generally pay only your in-network copay, coinsurance, and deductible
Your health plan and the provider must resolve any additional payment disputes between themselves

Click here for additional information.

When Surprise Billing Protections May Not Apply

There are situations where out-of-network billing may still apply, such as:

Elective care you choose to receive from an out-of-network provider or at an out-of-network facility, after being informed of potential costs
Certain services where you voluntarily sign a notice and consent form agreeing to receive care from an out-of-network provider and to accept possible balance billing (the law strictly limits when this is allowed)

Even in these situations, our staff will guide you through your options and help you understand your estimated costs before scheduling surgery whenever possible.

How Richmond Plastic Surgeons Helps You Navigate Out-of-Network Issues

Our goal is always to take the stress out of coverage. Here’s how we support you:

Benefits verification: We review your insurance information and, when appropriate, check whether you have out-of-network benefits and how they apply to your planned procedure.
Clear estimates: Before elective procedures, we provide a good-faith estimate of your expected financial responsibility, based on the information from your insurer at that time.
Claims submission: In many cases, we submit claims on your behalf so you don’t have to manage that paperwork on your own.
Problem-solving: If something on your bill doesn’t look right, our billing team will help you review it and, when appropriate, help you speak with your health plan.

If your plan includes out-of-network benefits, they may help offset part of your costs. If not, we will still work with you to look at options—including payment arrangements—so you can access the care you need.

What You Can Do to Avoid Surprises

Call your health plan before non-emergency procedures and ask:

Is Richmond Plastic Surgeons in-network for my plan?
What are my in-network and out-of-network benefits?
What are my current deductible and out-of-pocket amounts?

Ask for information in writing (email, portal message, or letter) when possible
Share any pre-determination letters or estimate information with our team so we can make sure everyone is working from the same details

If You Think You’ve Been Wrongly Billed

Contact our office first. Many issues can be resolved by clarifying coding, benefits, or the claim processing.
You can also contact the federal No Surprises Help Desk at 1-800-985-3059 or visit the Centers for Medicare & Medicaid Services website at cms.gov/medical-bill-rights for more information and to file a complaint.