The same MRI or CT scan can cost you a modest copay or more than a thousand dollars, depending on one thing: whether the imaging center is in your insurance plan’s network. Here’s why the gap is so large, when federal law protects you from surprise bills and how to check before you book.
Key takeaways
- In-network imaging centers have agreed prices with your insurer, so you pay only your plan’s normal cost sharing.
- Out of network, you may face higher coinsurance, a separate deductible and a bill for the difference between the center’s charge and what your plan pays.
- HMO and EPO plans often pay nothing for non-emergency out-of-network care.
- The No Surprises Act protects you in emergencies and when an out-of-network radiologist works at an in-network hospital, but usually not when you choose an out-of-network center yourself.
- Check both the imaging center and the radiology group before your appointment.
What «in network» means
Your insurer signs contracts with hospitals, imaging centers and doctors. In those contracts, the provider agrees to accept a set price, often called the allowed amount. You pay your deductible, copay or coinsurance based on that price, and the provider can’t charge you more.
An out-of-network provider has no contract with your plan. It can set its own price, and your plan may pay less or nothing.
Why out of network costs more
Three things push your bill up.
1. Higher cost sharing. Many PPO plans charge a higher coinsurance out of network, for example 40% instead of 20%. Some have a separate, larger deductible for out-of-network care.
2. Balance billing. Your plan pays based on its allowed amount, not the center’s full charge. The out-of-network center can bill you for the difference. This is called balance billing, and it’s often the biggest part of the bill.
3. Weaker limits. Many plans don’t count out-of-network spending toward your in-network out-of-pocket maximum, and balance-billed amounts usually don’t count at all.
If you have an HMO or EPO plan, the difference can be even bigger: these plans often cover no out-of-network care except emergencies.
A worked example
The numbers below are hypothetical, to show how the math works. Your plan’s rules and prices will be different. Assume you’ve already met your deductible.
| Situation | How it works | What you pay |
|---|---|---|
| In-network MRI | Plan’s agreed price is $600; you pay 20% coinsurance | $120 |
| Out-of-network MRI, PPO plan | Center charges $2,000; plan allows $600 and you pay 40% of that ($240), plus the $1,400 difference | $1,640 |
| Out-of-network MRI, HMO or EPO plan | Plan pays nothing for non-emergency out-of-network care | $2,000 |
When the No Surprises Act protects you
Since January 1, 2022, the federal No Surprises Act has protected most people with private health insurance from many surprise out-of-network bills. For imaging, it matters in two main situations.
Emergencies. If you get a CT or other scan as part of emergency care, you can’t be balance billed, even at an out-of-network hospital. You pay only your in-network cost sharing.
Out-of-network radiologists at in-network facilities. You might book a scan at an in-network hospital, but the radiologist who reads it belongs to an out-of-network group. Radiology is one of the services where out-of-network providers at in-network hospitals and ambulatory surgery centers can’t balance bill you. They can’t ask you to give up that protection, either.
When these protections apply, you pay only your normal in-network copay, coinsurance and deductible. Your plan must count what you pay toward your deductible and out-of-pocket limit.
When it usually doesn’t protect you
The law is designed for bills you couldn’t avoid. If you choose a scheduled scan at an out-of-network imaging center, you’re generally responsible for the out-of-network costs.
For some other services at in-network facilities, providers can ask you to sign a notice and consent form giving up your protections. You’re never required to sign it. If you’re handed one, you can ask for an in-network provider instead.
How to check before you book
- Check the imaging center. Use your insurer’s online directory, then call the insurer to confirm. Directories can be out of date.
- Check the radiology group. Ask the center which group reads its scans and confirm that the group is in network too.
- Confirm the location. A health system can be in network at one site and out of network at another.
- Check prior authorization. Many plans require approval for MRI, CT and PET. Out-of-network care may need extra approval.
- Ask for a cost estimate. Ask for your expected cost under your plan, in writing if possible.
- Write it down. Note the date, the name of the person you spoke to and a reference number.
If your doctor sends you to a specific center, you can ask for an in-network alternative.
If you get an out-of-network bill
- Compare the bill with your Explanation of Benefits (EOB) from your insurer.
- If you think the No Surprises Act applies, contact the No Surprises Help Desk at 1-800-985-3059.
- If you chose out-of-network care, call the provider and ask for a discount, a cash price or a payment plan.
- You can also file an appeal with your insurer if you think the claim was processed wrong.
If you don’t have insurance
Networks don’t apply, but you have a different protection. Providers usually must give you a good faith estimate if you schedule at least three business days ahead or if you ask for one. If your bill is at least $400 more than the estimate, you may be able to dispute it. Our guide to self-pay imaging explains how to ask for a cash price.
Frequently asked questions
Can an in-network hospital use an out-of-network radiologist? Yes, but for most people with private insurance, the No Surprises Act stops that radiologist from balance billing you. You pay only your in-network cost sharing.
Is it ever cheaper to go out of network? Sometimes. A low cash price at an independent center can beat a high in-network price if you have a big deductible. Compare the total, and remember that cash payments may not count toward your deductible.
Do the protections apply to Medicare? Medicare and Medicaid already have their own rules that limit what providers can bill you. The No Surprises Act mainly covers private and employer health plans.
What if my insurer’s directory was wrong? If you relied on a directory listing that said a provider was in network, federal rules may limit what you owe to in-network cost sharing. Keep a screenshot of the directory listing.
Sources
- Centers for Medicare & Medicaid Services (CMS): Medical bill rights and the No Surprises Act.
- Federal model notice: Your rights and protections against surprise medical bills.
- HealthCare.gov: Glossary (balance billing, out-of-pocket maximum).
This article is for general information only and isn’t financial or legal advice. Plans differ, so check your plan documents and call your insurer before your scan.