By Counterforce Health Team — 15 May 2025

Out-of-Network Denial Appeals: The Complete Guide to Overturning Surprise Medical Bills

The Surprise Medical Bill Crisis: Understanding Out-of-Network Denials

You did everything right. You checked that the hospital was in-network before your procedure. You verified your insurance coverage. You even called your insurer to confirm benefits.

Then the bills arrived.

Suddenly, you're facing thousands of dollars in out-of-network charges. Your anesthesiologist, radiologist, or emergency physician—providers you never chose and possibly never met—were out-of-network, and your insurance company is refusing to cover their services at in-network rates.

You've just experienced what millions of Americans face each year: a surprise medical bill.

According to a comprehensive study by the American Medical Association, approximately 20% of in-network hospitalizations result in out-of-network charges. Researchers at the Georgetown University Health Policy Institute found that the average surprise bill for emergency care exceeds $2,600, while out-of-network surgeons and anesthesiologists can add more than $3,600 to a patient's costs.

The good news is that recent legislation, particularly the No Surprises Act which took full effect in January 2022, provides powerful new protections. Even better: with the right approach, many out-of-network denials can be successfully appealed, even those that initially seem hopeless.

This comprehensive guide will walk you through the entire process of appealing out-of-network denials and fighting surprise medical bills. We'll cover your legal rights, practical strategies that have helped thousands of patients, and step-by-step instructions for crafting effective appeals.

The No Surprises Act and State Laws

The No Surprises Act: Federal Protection Against Unexpected Bills

The No Surprises Act represents the most significant federal protection against surprise medical bills in U.S. history. This legislation, which took effect on January 1, 2022, provides comprehensive protection against surprise bills in three key scenarios:

Emergency services: All emergency care must be covered at in-network rates, regardless of where it's provided, until the patient is stable.
Non-emergency services at in-network facilities: If you receive treatment at an in-network hospital or ambulatory surgical center, all providers there must treat you at in-network rates, even if they're individually out-of-network.
Air ambulance services: Air ambulance services must be covered at in-network rates, regardless of whether the provider is in your insurer's network.

The Kaiser Family Foundation estimates that the No Surprises Act protects consumers from approximately 10 million surprise bills annually. Under this law, patients cannot be billed more than their in-network cost-sharing amount (deductibles, copayments, or coinsurance) for these services.

The Centers for Medicare & Medicaid Services explains that the law also requires providers to give clear advance notice about out-of-network care, costs, and options for patients in non-emergency situations.

State Laws: Additional Layers of Protection

While the No Surprises Act provides national baseline protection, many states have enacted their own laws that may offer even stronger safeguards. According to the Commonwealth Fund, 33 states have laws addressing surprise medical billing, though the comprehensiveness of these protections varies significantly.

States like California, New York, and Colorado have particularly robust protections. For example, New York's Emergency Services and Surprise Bills law (enacted before the federal legislation) created an independent dispute resolution process that has helped thousands of patients avoid unfair bills.

It's important to know that state laws may provide additional protections beyond the federal law in certain circumstances. The National Conference of State Legislatures maintains an updated database of state-level protections that can be an invaluable resource when appealing a denial.

Common Reasons for Out-of-Network Denials (And How to Counter Them)

Understanding why your claim was denied is the first crucial step in formulating an effective appeal. Insurance companies typically deny out-of-network claims for several specific reasons. Let's examine each common denial reason and the most effective counterarguments.

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"You Chose to Go Out-of-Network"

This is among the most common justifications for denials, even when patients had no practical choice in the matter. Insurers often claim that you voluntarily selected an out-of-network provider when, in reality, you had no knowledge or control over who would be involved in your care.

Effective counter-strategy: Document how you had no reasonable opportunity to select an in-network provider. For emergency services, emphasize that the Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to treat patients regardless of insurance status. For scheduled procedures at in-network facilities, gather evidence showing you weren't informed that certain providers would be out-of-network.

The Patient Advocate Foundation recommends obtaining written statements from your primary provider confirming you had no opportunity to select specific ancillary providers like anesthesiologists or radiologists.

"The Service Wasn't Medically Necessary"

Insurers frequently deny out-of-network claims by questioning medical necessity, especially for emergency services after the fact.

Effective counter-strategy: Gather comprehensive medical documentation describing your symptoms and condition at the time of seeking care. The No Surprises Act specifically requires insurers to cover emergency services based on the "prudent layperson standard" - meaning coverage is based on what a reasonable person would consider an emergency, not a retroactive medical determination.

According to the American College of Emergency Physicians, this standard is crucial for protecting patients. Your appeal should emphasize your symptoms at the time of seeking care, not the eventual diagnosis.

"Insufficient Attempt to Find In-Network Care"

Some insurers claim that patients didn't make reasonable efforts to find in-network providers before receiving out-of-network care.

Effective counter-strategy: Document all attempts to identify in-network providers. This includes screenshots of provider searches on your insurer's website, records of phone calls to your insurance company, and any referrals from in-network doctors. The American Hospital Association notes that insurance directories are often inaccurate, which can strengthen your appeal if you relied on incorrect information.

"Lack of Prior Authorization"

Insurers often cite lack of prior authorization as grounds for denying out-of-network claims, even in situations where obtaining authorization was impossible.

Effective counter-strategy: For emergency situations, emphasize that prior authorization is not required under the No Surprises Act. For non-emergency situations, document any attempts to obtain authorization. If the procedure was urgent or medically necessary, have your physician provide a letter explaining why waiting for authorization would have been detrimental to your health.

The National Association of Insurance Commissioners confirms that emergency services should not require prior authorization and should be covered at in-network rates regardless of where they're received.

Step-by-Step Guide to Appealing Out-of-Network Denials

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Step 1: Understand Your Specific Situation and Applicable Protections

Before launching your appeal, determine exactly which legal protections apply to your case. Ask yourself these questions:

Was this emergency care?
Was the facility in-network but certain providers out-of-network?
Did the service occur after January 1, 2022 (when the No Surprises Act took effect)?
What additional protections does your state provide?

Your answers will shape your appeal strategy. For example, if you received emergency care after January 1, 2022, the No Surprises Act clearly states your insurer must cover these services at in-network rates.

The Consumer Financial Protection Bureau provides an excellent summary of these rights that you can reference in your appeal.

Step 2: Gather Essential Documentation

Successful appeals are built on comprehensive documentation. Collect:

Medical records describing your condition and treatment
All bills and Explanation of Benefits (EOB) statements
Documentation of any attempts to find in-network providers
Records of communications with your insurer and providers
Your insurance policy, particularly sections on out-of-network coverage and emergency services
A detailed timeline of events

For surprise bills from in-network facilities, the Patient Advocate Foundation recommends obtaining a statement from the facility confirming they were in-network at the time of your treatment.

Step 3: Contact Both Your Provider and Insurer

Before formally appealing, contact both the provider who billed you and your insurance company. Some issues can be resolved without a formal appeal.

When speaking with providers:

Explain that you were unaware they were out-of-network
Ask if they'll accept in-network payment rates
Inquire whether they can submit additional information to your insurer

When speaking with your insurer:

Clarify why your claim was denied
Ask about your appeal rights and deadlines
Request the specific policy language they're using to deny your claim

Document all communications, including dates, names of representatives, reference numbers, and summaries of conversations.

Step 4: Write a Comprehensive Appeal Letter

Your appeal letter should be professional, fact-based, and specifically address the reason for denial. Include:

Your name, policy number, claim number, and date of service
A clear opening statement identifying the denied claim and requesting reconsideration
Specific reference to applicable laws (No Surprises Act and/or state protections)
A detailed explanation of why your situation qualifies for coverage
Supporting evidence from your documentation
A specific request for in-network processing of your claim
Your contact information

The Georgetown University Health Policy Institute suggests including relevant research on usual and customary rates for the services you received if the insurer claims the out-of-network charges were excessive.

Step 5: Submit Your Internal Appeal and Track Progress

Submit your appeal according to your insurer's specified procedures, which should be outlined in your denial letter or policy documents. Always:

Send appeals via certified mail or secure electronic submission
Request a return receipt or confirmation
Keep copies of everything you submit
Note the date of submission and expected response timeframe
Follow up if you don't receive a response within the stated timeframe

Under the Affordable Care Act, insurers must respond to internal appeals within 30 days for pre-service claims and 60 days for post-service claims. For urgent care claims, they must respond within 72 hours.

Step 6: Request an External Review If Necessary

If your internal appeal is denied, you have the right to an external review by an independent third party. The No Surprises Act Help Desk can provide guidance on accessing this process.

For external reviews:

Submit your request within four months of the internal appeal denial
Include all documentation from your internal appeal plus any new evidence
Be aware that the external reviewer's decision is binding on the insurance company

The National Association of Insurance Commissioners reports that approximately 40% of external reviews result in decisions favoring the patient, so this step is well worth pursuing.

Emergency Care, Ambulance Services, and More

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Emergency Room Visits

Emergency services receive the strongest protections under both the No Surprises Act and most state laws. If you received emergency care (including post-stabilization care), your insurer must cover these services at in-network rates regardless of whether the facility or providers were in-network.

According to the Centers for Medicare & Medicaid Services, the prudent layperson standard applies, meaning coverage is based on what a reasonable person would consider an emergency based on symptoms, not the final diagnosis.

When appealing emergency care denials:

Focus on your symptoms and condition when you sought care
Reference the prudent layperson standard explicitly
Cite the No Surprises Act's emergency care protections
Include documentation of your symptoms from medical records

Ambulance Services

Ground ambulance services remain a notable gap in the No Surprises Act, but air ambulance services are covered. For ground ambulance bills:

Check your state laws, as some states do provide protections for ground ambulance services
Verify whether the ambulance service has a contract with your insurer
Request itemized bills and question any unusual charges

The American Ambulance Association notes that many ambulance services will work with patients on payment plans or reduced rates when insurance doesn't fully cover services.

Mental Health Services

Mental health services often face higher rates of out-of-network care due to inadequate provider networks. When appealing these denials:

Reference the Mental Health Parity and Addiction Equity Act, which requires insurers to cover mental health services comparably to medical services
Document any attempts to find in-network providers
If no in-network providers were available within a reasonable distance or timeframe, emphasize this network inadequacy in your appeal

The National Alliance on Mental Illness provides specialized resources for appealing mental health claim denials.

Success Stories: Real Patients Who Fought and Won

Case Study 1: Emergency Surgery Out-of-Network Charges Reversed

Michael T. from Boston was rushed to the nearest hospital with acute appendicitis. Although the hospital was in-network, he later received a $3,800 bill because the surgeon was out-of-network. Michael appealed by citing the No Surprises Act's emergency care provisions and documenting that he had no choice in selecting his surgeon during an emergency.

His appeal emphasized the life-threatening nature of appendicitis and included medical records detailing his severe symptoms upon arrival. After his initial appeal was denied, Michael requested an external review. The independent reviewer determined that the insurer was required to process the surgeon's services at in-network rates under federal law. The $3,800 bill was reduced to $380, his standard in-network copay for surgery.

Case Study 2: Network Adequacy Appeal Success

Jennifer L. from rural Colorado needed specialized orthopedic care following a complex fracture. The nearest in-network specialist was over 200 miles away, so she sought care from a closer out-of-network provider. Her initial claim was denied.

Jennifer's appeal focused on network inadequacy, documenting that no in-network providers were available within a reasonable distance. She included statements from her primary care physician explaining why traveling such a distance would be medically inadvisable given her condition. She also referenced Colorado's network adequacy requirements, which specify maximum travel distances for specialized care.

Her insurer reversed the denial based on this documentation and processed the claim at in-network rates, saving her over $5,200.

Case Study 3: Incorrect Provider Information Appeal

David S. from Atlanta scheduled surgery at an in-network hospital and specifically confirmed that his surgeon was in-network using his insurer's provider directory. After the procedure, he received a $4,300 bill because the surgeon was actually out-of-network; the directory was outdated.

David's appeal included screenshots of the provider directory showing the surgeon as in-network on the date he checked, records of his phone call to the insurance company confirming coverage, and a reference to provisions in the No Surprises Act regarding the accuracy of provider directories. His insurer acknowledged the error and processed the claim at in-network rates.

Preventing Surprise Bills: Proactive Strategies

While knowing how to appeal is crucial, preventing surprise bills is even better. Here are proactive strategies recommended by the Healthcare Financial Management Association:

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Before Scheduled Procedures

Verify network status of both facility and providers: Don't just ask "Do you take my insurance?" Instead, ask "Are you in-network with my specific insurance plan?" Get confirmation in writing when possible.
Request all providers involved: For surgeries or complex procedures, ask for a list of all providers who might be involved (surgeons, anesthesiologists, radiologists, assistants) and verify each one's network status.
Get cost estimates in writing: The Hospital Price Transparency Rule requires hospitals to provide clear, accessible pricing information. Request detailed estimates before proceeding.
Discuss alternatives: If you discover out-of-network providers will be involved, ask your doctor if in-network alternatives are available.
Document everything: Keep records of all communications about coverage, including names, dates, and summaries of what was discussed.

For Emergency Situations

While emergencies don't allow for advance planning, you can:

Know nearby in-network facilities: Familiarize yourself with which local emergency rooms are in your network, though in true emergencies, always go to the nearest facility.
Carry insurance information: Keep your insurance card and a contact number for your insurer readily accessible.
Understand your rights: Knowing that emergency services must be covered at in-network rates can give you confidence in seeking necessary care.

Frequently Asked Questions About Out-of-Network Denials and Appeals

Does the No Surprises Act cover all out-of-network services?

No. While the No Surprises Act provides substantial protections, it primarily covers emergency services, out-of-network providers at in-network facilities, and air ambulance services. It doesn't cover:

Ground ambulance services
Non-emergency care at out-of-network facilities
Services at certain non-hospital facilities
International care

For these situations, check your specific insurance policy and state laws, which may provide additional protections. The American Hospital Association offers a detailed breakdown of what is and isn't covered.

Can providers still balance bill me in certain situations?

In limited circumstances, yes. The No Surprises Act does allow balance billing if:

You receive non-emergency services at an out-of-network facility
You knowingly and voluntarily consent to out-of-network care

However, for consent to be valid, providers must:

Give you a written notice explaining your rights
Provide an estimate of charges
Offer information about in-network alternatives
Obtain your written consent

This consent exception doesn't apply to emergency services, ancillary services (like anesthesiology, radiology, lab services), or assistant surgeons. The Georgetown University Center on Health Insurance Reforms provides detailed guidance on these exceptions.

How do I know if my state has additional protections?

The Commonwealth Fund's Balance Billing Protection Map provides a comprehensive overview of state-level protections. Additionally, your state's insurance department website typically details specific protections. The No Surprises Act creates a "floor" of protection, and state laws may offer additional safeguards beyond the federal requirements.

What if I already paid an out-of-network bill that should have been covered?

If you've already paid a bill that should have been protected under the No Surprises Act or state laws, you can still seek reimbursement. According to the Centers for Medicare & Medicaid Services, you should:

Contact both the provider and your insurer explaining the situation
Request a refund from the provider
File a formal complaint with your state insurance department or the federal No Surprises Help Desk if necessary

You generally have up to 120 days from payment to request a refund.

How long does the appeal process typically take?

Under the Affordable Care Act, insurers must respond to standard internal appeals within 30 days for pre-service claims and 60 days for post-service claims. Expedited appeals for urgent cases must be decided within 72 hours.

If you proceed to external review, the timeline is typically 45 days from submission, though expedited external reviews for urgent cases must be completed within 72 hours.

The entire process from initial denial to external review resolution typically takes 3-4 months, though complex cases may take longer. The Department of Labor's Employee Benefits Security Administration provides a comprehensive timeline of the appeals process.

The Bottom Line: Know Your Rights and Fight Back

Surprise medical bills and out-of-network denials can be financially devastating, but they're not inevitable. Thanks to the No Surprises Act and various state protections, patients now have stronger legal grounds than ever to fight unfair billing practices.

The key is understanding your rights, gathering thorough documentation, and pursuing appeals persistently. Remember that insurers count on patients giving up, data from the Kaiser Family Foundation shows that less than 1% of denied claims are appealed, yet many appeals succeed when patients persist.

At Counterforce Health, we've helped thousands of patients navigate the complex world of out-of-network denials and surprise bills. Our AI-powered appeal tools can generate customized appeal letters that cite relevant laws and regulations specific to your situation.

Don't become another statistic, fight back against unfair out-of-network denials and take control of your healthcare costs.

Fight For Your Rights Today

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