Understanding Out-of-Network Care: What It Means for You
Yes, we accept and bill your insurance.
This comprehensive guide will help you understand exactly what "out-of-network" means for your care at Dr. Kamrava's office, how we work with your insurance, and why this approach often benefits patients. We believe in complete transparency about our process, your costs, and your protections under federal law.
Your Complete Guide to Out-of-Network Insurance
Many patients feel confused or concerned when they hear "out-of-network," often assuming it means their insurance won't be accepted or that they'll face unexpected costs. The reality is quite different, and understanding the facts can help you make informed decisions about your healthcare.
This handout contains everything you need to know about how out-of-network care works, what protections you have under federal law, and how our office ensures you receive quality care while managing insurance effectively. We've included real data, step-by-step processes, and resources to help you navigate this system with confidence.
Our goal is simple: to provide excellent medical care while handling the complex insurance processes so you can focus on your health and recovery.
Understanding Out-of-Network Care
What It Means for You
"Yes, we accept and bill your insurance."
At Dr. Kamrava's practice, we understand that insurance terminology can be confusing. When patients hear "out-of-network," they often worry that their insurance won't be accepted or that they'll face surprise bills. We want to address these concerns directly and explain exactly how our process works to protect and benefit you.
This guide will walk you through every aspect of out-of-network care, from basic definitions to detailed explanations of federal protections. You'll learn why some physicians choose to remain out-of-network, how it can actually benefit patients, and what to expect throughout your treatment process.
What "Out-of-Network" Really Means
In-Network
A doctor signs a contract with an insurance company agreeing to accept a fixed "rate schedule" for each service. These rates are set by the insurer, not by the physician.
  • Pre-negotiated rates
  • Contract obligations
  • Limited flexibility
Out-of-Network
The doctor has not signed that contract. But the doctor can still bill your insurance. You can still use your benefits. The difference is how the price is determined (pre-set vs. negotiated).
  • Fair negotiation
  • Quality-based care
  • Direct billing

Important: Out-of-network does not mean "we don't take your insurance." It simply means the doctor is not bound to the insurer's fee schedule and can negotiate with your insurance company for fair payment.
The key distinction lies in how medical services are priced and reimbursed. In-network providers agree to accept whatever rates insurance companies set, often significantly below the actual cost of providing quality care. Out-of-network providers maintain the ability to negotiate fair compensation while still working directly with your insurance company.
This difference in approach doesn't change your access to care or your ability to use insurance benefits. Instead, it often results in better outcomes for patients because providers can focus on quality rather than volume, and can invest in the latest technology and techniques without being constrained by artificially low reimbursement rates.
Do We Accept Your Insurance?
We bill all PPO and most non-HMO plans directly
Your insurance benefits remain fully available, and we handle all the paperwork and communication with your insurer on your behalf.
Surgeries are only scheduled after your insurance has authorized/approved them
We obtain preauthorization before scheduling any surgery to confirm coverage in advance.
HMO plans require special consideration
If you have an HMO, your plan requires you to stay in-network. We can discuss cash pricing or help you request an exception from your plan.
✓ YES - We Accept
  • PPO Plans
  • Most Non-HMO Plans
  • Medicare Advantage (most)
  • Traditional Medicare
HMO - Special Process
We can help you:
  • Request coverage exceptions
  • Explore cash pricing options
  • Navigate plan requirements
The vast majority of patients have insurance plans that work seamlessly with our out-of-network process. We've developed streamlined procedures to verify coverage, obtain necessary authorizations, and ensure smooth processing of your claims. Our experienced billing team works directly with insurance companies to maximize your benefits and minimize your out-of-pocket costs.
Why Don't All Doctors Stay In-Network?
Patients often assume insurance pays doctors thousands for procedures. Reality: physician in-network payments for complex procedures are often shockingly low (physician component only — excludes facility, anesthesia, pathology):
*These ranges reflect physician services only, based on internal billing data and public sources. Actual amounts vary by insurer, region, and case specifics.
The Reality Behind Medical Bills
Most of the "bill" you see in the hospital goes to the facility, anesthesia, and pathology. The physician portion is a fraction of the total. Accepting in-network rates at these levels can make it impossible for high-intensity specialty practices to cover costs and maintain quality.
Consider that these low reimbursement rates must cover years of specialized training, ongoing education, malpractice insurance, staff salaries, advanced equipment, and facility costs. When reimbursement doesn't cover these essential expenses, quality of care inevitably suffers.
Why Some Doctors Still Stay In-Network
01
Patient Acquisition
Being in-network helps a doctor get patients from insurer directories. For many physicians, insurer referrals are their main source of business.
02
Institutional Requirements
In-network participation is often necessary for hospital employment or large group contracts, regardless of the financial impact on individual practices.
03
Volume-Based Business Model
Some practices compensate for low per-service rates by seeing higher volumes of patients, though this can impact time spent with each patient.

What Out-of-Network Can Signal
When a physician can successfully remain out-of-network, it's often because they are well-known and trusted by other physicians. They receive referrals based on reputation and outcomes, not just insurer listings. This can be a sign of a physician's established quality and independence.
Insurer Directory Referrals
  • Based on network participation
  • Volume-driven
  • Contract requirements
Physician Reputation Referrals
  • Based on outcomes and quality
  • Relationship-driven
  • Merit-based recognition
What Happens When You're Out-of-Network at Our Office
Step-by-Step Process:
1
Benefits Check
We verify your coverage and explain your plan's rules in detail before any treatment begins.
2
Preauthorization
For any surgery, we obtain authorization before scheduling to confirm coverage approval.
3
Treatment
You receive high-quality care from our experienced team in a comfortable, modern facility.
4
Direct Billing
We bill your insurance directly - you don't have to handle claims or reimbursement paperwork.
5
Negotiation
If the insurer underpays, we negotiate on your behalf to ensure fair compensation.
6
Independent Dispute Resolution (IDR)
If negotiation fails, we can pursue IDR under the federal No Surprises Act, where a neutral arbiter decides fair payment.
7
Patient Responsibility
You are responsible for deductibles and coinsurance as required by your plan.
We do not send patients to collections.
Throughout this entire process, our dedicated billing team keeps you informed and handles all communication with insurance companies. You can focus on your health and recovery while we manage the complex administrative details. Our commitment is to transparency - you'll always know what to expect regarding costs and coverage before treatment begins.
The No Surprises Act (Detailed Explanation)
Purpose
Protects patients from unexpected out-of-network bills in emergencies and certain non-emergency facility-based settings.
Open Negotiation
Both sides try to settle on a reasonable payment through good-faith negotiation processes.
Independent Dispute Resolution (IDR)
For NSA-qualifying claims, if negotiation fails, we can pursue Independent Dispute Resolution.
Key Protections Under Federal Law:
  • The Arbiter's Role: A certified third party reviews each offer and chooses one. This decision is binding on both parties.
  • Deadlines: Strict federal timelines apply to ensure prompt resolution of disputes.
  • Patient Impact: For NSA-covered care (emergencies, out-of-network care at in-network facilities, air ambulance), patients are responsible only for in-network cost sharing. Balance billing protections apply specifically to these scenarios.
  • Limits: NSA protections don't apply to all scenarios (e.g., most ground ambulance services are excluded).
  • Our Compliance: We follow current CMS rules and use the IDR process where appropriate.
The No Surprises Act represents the most significant patient protection legislation in decades. It creates a fair, transparent process that benefits both patients and healthcare providers by establishing clear rules for out-of-network billing disputes. This federal law ensures that while providers and insurers negotiate fair payment, patients are protected from unexpected costs beyond their normal plan obligations.
Under this law, you have the right to receive a good faith estimate of costs before treatment, and you're protected from balance billing in specific out-of-network scenarios defined by the law (primarily emergencies and care at in-network facilities). Our office fully complies with these regulations and uses them to advocate for both fair provider compensation and patient protection.
What This Means for You
Take-Home Points
✓ We accept and bill your insurance
Except HMOs - we handle all paperwork and communication with your insurer directly.
✓ Surgeries only proceed after prior approval
We obtain all necessary authorizations before scheduling any procedures.
✓ We negotiate with insurers so you don't have to
Our experienced billing team handles all insurance negotiations on your behalf.
✓ No collections during disputes
We do not send patients to collections while insurer disputes are active.
✓ Transparent pricing
If insurance truly won't pay, your cost is reduced to our cash rate + billing team's fee, communicated upfront — no surprises.
✓ Standard deductibles apply
You are responsible for deductibles and coinsurance as required by your insurance plan.
Why This Benefits Patients:
Financial Benefits
  • We handle reimbursement directly with insurers so patients aren't caught in the middle of billing disputes
  • Patients often end up with lower out-of-pocket exposure than they would expect from an out-of-network situation
  • Transparent pricing with no hidden fees
Care Benefits
  • Focus on quality over quantity of patients
  • Investment in latest technology and techniques
  • Our process lets you focus on your health, while we focus on ensuring care is fairly reimbursed
Resources and Contact Information
FAIR Health Consumer Estimator Tool
Use this free tool to estimate healthcare costs in your area and understand typical insurance reimbursement rates.
Website: www.fairhealthconsumer.org
CMS No Surprises Act Consumer Fact Sheet
Official government information about your rights and protections under federal healthcare billing laws.
Website: cms.gov/nosurprises
Our Billing Office
Our dedicated team is here to answer questions about insurance, billing, and payment options.
Phone: Available during business hours
Email: Direct access for billing inquiries
Disclaimer: Information reflects physician services only. Actual amounts vary by insurer, region, and case specifics. Patients are responsible for deductible and coinsurance as required by law.