What is out-of-network balance medical billing?



Out-of-network health care: small words with big impact

It’s happened to one third of privately insured people in the U.S.1: You receive medical care and a few weeks later, a piece of mail arrives telling you the doctor, specialist, or service provider was “out-of-network.” Maybe you’re not sure what that means. And you’re even less sure how it happened, or if it’s actually correct. But what you do realize from the paperwork is that a hefty medical bill may be on the way.

Don’t panic – we’ve got your back

Naviguard® was created to help members deal with out-of-network balance medical bills and to provide guidance on how to avoid them. Our insurance specialists and expert negotiators have decades of health care experience and work on behalf of members to resolve out-of-network balance medical bills. It’s our primary focus.

If your UnitedHealthcare plan includes Naviguard, our services are available to you at no additional cost. Ask your employer or call UnitedHealthcare Member Services to find out if your plan includes Naviguard.

In this article, we’ll focus on exactly what “out-of-network” means, how it happens, and what to do if you get an out-of-network balance medical bill.

Out-of-network: what it means

Insurance companies contract with certain providers and facilities to secure a network discount for the services they provide. Those are considered “in-network” providers. Out-of-network means that there’s no contract between the provider and insurance company.

As a result, if you see an out-of-network provider, there is no contract controlling costs and you may face a significant medical bill from them. In many cases, out-of-network providers charge prices that are much higher than market rates.

How balance medical bills happen, and how you may be able to avoid them

Under the No Surprises Act (NSA), providers of certain types of services are prohibited from billing you directly for unexpected balance medical bills. But this protection only applies to certain services, like emergency services (excluding ground ambulances) or when an out-of-network provider is involved in your care at an in-network facility. This means you could still wind up with balance bills for out-of-network charges.

Knowing how these bills happen may give you some power to prevent them.

1. No prior agreement with the provider

You may face out-of-network balance medical bills that are not subject to the No Surprises Act or exceed the allowed amount under your plan. This can happen if you see a provider that hasn’t agreed to a negotiated fee with your insurance provider.

How to prevent it: Understand your plan thoroughly — from who’s in your provider network, to your family deductibles, to your co-pays and co-insurance. If you choose to see a provider not in your network, get an estimate of the costs ahead of time. If your plan includes some out-of-network benefits, understand those ahead of time so you’re better prepared for the bill.  

2. Referral from your in-network doctor

When your provider suggests you see a specialist or have a procedure, you may assume — incorrectly — that it’s all in-network. Fact is, outside facilities that do lab work and pathology tests, and some specialty providers like radiologists and anesthesiologists, may be out-of-network.  

How to prevent it: In non-emergency situations, verify ahead of time with your plan administrator that every provider and procedure is in-network. If a service or specialist is not in-network, ask your primary doctor for in-network options.

3. Ambulance costs

Although the No Surprises Act prohibits providers from billing patients for certain types of services, including emergency care (and air ambulances), you may still be billed by out-of-network providers for the ground ambulance ride to a hospital and for the difference between the total bill and the amount allowed by your plan.

Can you prevent it? Not always. But it’s helpful to know ahead of time.

4. Waivers may work against you

An out-of-network provider may ask you to sign a form that waives some of your protections under the No Surprises Act. Be sure to read any agreement you’re asked to sign, especially if it includes cost estimates — and ask questions about what you’ll have to pay beyond what insurance covers. Even if the math looks correct, claims could be processed as out-of-network for a number of reasons:

  • A referral from your doctor for another provider, specialist, or service was missing at the time your claim was processed
  • A secondary out-of-network provider, such as an anesthesiologist, submitted their claim before the in-network facility did
  • An emergency situation was processed as a non-emergency

What to do: If you think the out-of-network claim is wrong or your plan benefits were applied incorrectly, contact your plan administrator right away. Or, if you think you’re missing a referral, give your provider a call. Responding quickly can help keep incorrect bills from filling your mailbox.

Use our expertise – we’re here for you

At, you’ll find a variety of resources, including helpful tips on avoiding, understanding, dealing with, and negotiating out-of-network balance bills.

Naviguard members can use our full suite of resources and services, which will lead you step-by-step through an out-of-network billing claim and help prepare you to negotiate with out-of-network providers.

If you’re a member with a qualifying out-of-network claim we may be able to pair you with a dedicated Advisor who will personally guide you through the entire process and, depending on the claim, negotiate with providers on your behalf. We’re here to help however we can.




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