The top out-of-network health care cost risks



The secret to minimizing out-of-network health care risk

When it comes to out-of-network health care costs, the more you know, the better. Easier said than done, right? Well, that’s why Naviguard® is here. We help people navigate the confusing world of out-of-network health care so you can make smart decisions about your care and steer clear of excessive balance medical bills.

One third of privately insured people have received an unexpected out-of-network balance bill.1 What’s the secret to not getting one? Get ahead of them. In other words, know when you’re most at risk of going out-of-network so you can hopefully avoid getting the balance bill. But before we get into the specifics, let’s start with the basics.

What does “out-of-network” care mean?

Out-of-network” means the health care provider is outside your plan’s network and there’s no contracted or negotiated rate between them and your plan. While in-network providers agree in advance to specific rates, out-of-network providers do not. Their fees may be much higher than market rates and higher than the amount allowed under your plan.

How to know what’s out-of-network for your plan

Become familiar with your health plan to know what you’re responsible for paying and to plan for potential bills. Before any doctor visit, surgery or procedure, log in to your account to check your plan details, then use the provider search tool to see if your provider is in your network.

You can also call the number on the back of your health plan ID card to find an in-network provider. Taking the time to understand your plan is worth it.

Out-of-network balance medical bills often occur when your doctor involves additional providers or specialists. These providers may operate separately from your main provider, which means they could be out-of-network for your plan.

Under the No Surprises Act (NSA), providers are prohibited from balance billing patients. But this protection only applies to specific services, like emergency services or when an out-of-network provider is involved in your care at an in-network facility. Ground ambulances are not covered by the NSA protections. Despite the NSA, there are many ways to wind up with an expensive balance medical bill for out-of-network charges you’re responsible for.

Good news: Many out-of-network health care costs can be avoided

It takes some effort up front to possibly save money down the line. Here’s what you should do to outsmart out-of-network costs: Before any medical visit or procedure, ask your physician what providers and services will be involved. Here are the most common out-of-network care situations:

The most common out-of-network
care situations

Member Advocacy
Getting referred to a specialist

When you’re referred or scheduled for a procedure outside of your primary care facility or provider.

Managing Pain
Managing pain (especially injections)

Any procedure that requires local or general anesthesiology, or being “put under,” means an anesthesiologist is needed to administer it.

Leaving a sample

When you leave a sample (like blood or urine) it’s sent to a laboratory for expert analysis.

Getting Scanned
Getting scanned

MRIs, X-Rays and CT scans are all times when a radiologist is needed to review the scan.

Having something removed

A biopsy involving organs, tissue, bodily fluid or cells will require a pathologist for analysis.

Someone Helping with Procedure
Someone is helping with the procedure

For more complicated procedures, doctors and surgeons may bring in a Physician’s Assistant or Surgical Assistant.

Ground ambulances

In an emergency, there isn’t enough time to make sure  the available ambulance provider is in-network.


If none of these scenarios apply to you, you’re probably not at risk for an out-of-network balance medical bill. However, you should always check your plan and ask at every step of the way to be sure.

If a service you’re getting is on the list, you don’t need to worry just yet. If the service is happening at an in-network facility, the risk of balance medical billing is low. You can try a few things to get in-network care or minimize costs:

  1. Call your provider and see if there’s an in-network option they can schedule
  2. Call the hospital or surgery center to see if they have any in-network providers that have privileges to perform care at that facility.
  3. Ask if you can get an upfront estimate for their services

Remember, Naviguard is here

Our purpose is to help people deal with unexpected out-of-network balance medical bills. We’ll review your bill to make sure you’ve been billed correctly and, if appropriate, we’ll negotiate with providers on your behalf. Our experts have helped tens of thousands of UnitedHealthcare members navigate difficult balance medical bills with significant success.

Our services are available at no additional cost to UnitedHealthcare members whose plan includes Naviguard. If you’re not a member, our resources may still help you understand your medical bills and avoid excessive charges.

Plus, Naviguard can help you get organized, gather the necessary paperwork, and build your case for negotiation and resolution. To learn more about the services we offer, talk to your employer or visit our About page.

P.S. Finding in-network care is easy with the UnitedHealthcare Provider Search tool.




  1. Khazan, O. (2023) The agony of medical bills. The Atlantic
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