What Is a Network Gap and How to Avoid Surprise Bills

A network gap occurs when care is coordinated among providers but one or more of those providers is outside your insurance network without adequate advance notice. The result is bills at out-of-network rates for care you thought was covered.

How network gaps happen

You chose an in-network hospital. You chose an in-network surgeon. But the surgeon uses a specific hospital-based laboratory, a specific radiologist, or a specific anesthesiology group that is out-of-network. You had no way to know this in advance and no practical opportunity to choose differently.

This pattern was the central problem the No Surprises Act was designed to address. For emergency care and for non-emergency care where you had no reasonable ability to choose your provider, balance billing is now prohibited for most situations.

Types of providers most likely to create gaps

Anesthesiologists assigned by the hospital or surgical center Radiologists who read imaging performed at an in-network facility Pathologists who analyze specimens from an in-network procedure Assistant surgeons called in during a procedure Hospitalists covering your care during an in-network hospital stay Laboratory services contracted separately from the hospital

These providers typically work at in-network facilities but may not themselves be in-network with your insurer.

Your rights under the No Surprises Act

For these ancillary providers at in-network facilities, you cannot be charged more than your in-network cost-sharing amount. This applies whether care was emergency or non-emergency, as long as you did not sign a voluntary waiver.

A standard hospital admission consent form is not a waiver of your No Surprises Act protections. A valid waiver must specifically identify the out-of-network provider, describe the estimated additional cost, and be signed before non-emergency care with time to seek an alternative.

Checking for gaps before scheduled procedures

Before any scheduled procedure at an in-network facility, call your insurer and ask specifically whether the following providers at that facility are in-network: the anesthesiology group, the laboratory, the radiology group, and any other known ancillary services for your procedure type.

If any are out-of-network, you have two options. Request an in-network alternative in writing to your surgeon or facility coordinator, or confirm with your insurer that the No Surprises Act applies and your out-of-pocket exposure is limited to in-network cost-sharing.

What to do if you receive an unexpected bill

Do not pay out-of-network rates for providers you had no ability to choose. Contact your insurer and ask them to process the claim under No Surprises Act protections. If the insurer or provider resists, file a complaint with the federal No Surprises Help Desk at 1-800-985-3059.

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Bill Advantage is a document literacy tool. Nothing in this article constitutes legal or medical advice.