In-Network Protection – Even When We’re Out of Network
Get In-Network Protection — Even When We’re Out of Network
Healthcare shouldn’t force you to choose between great care and financial certainty.
At our practice, you don’t have to.
Even though we are out-of-network with many insurance plans, we’ve built a system that allows patients to:
👉 Use their insurance
👉 Avoid surprise bills
👉 Pay predictable, transparent costs
How It Works
If your plan includes out-of-network (OON) benefits:
- We bill your insurance directly
- We limit your responsibility to typical in-network cost-sharing
- We do not balance bill you
If your insurance underpays:
👉 We pursue the difference directly with your insurer through:
- State dispute resolution (when applicable)
- Federal arbitration under the No Surprises Act
You are never involved in this process.
What You Pay
Your cost is predictable:
- Deductible
- Copay
- Coinsurance
👉 That’s it.
No surprise bills. No follow-up invoices months later.
Why Patients Choose Us
We Remove Insurance Barriers
No restrictive contracts. No compromised care decisions.
We Take on the Insurance Company
If they underpay, we fight it—not you.
We Eliminate Financial Uncertainty
You’ll know your responsibility upfront—and it won’t change.
What If My Plan Is Different?
If your plan:
- Has limited OON benefits, or
- Does not include OON coverage
We will:
- Clearly explain your options
- Provide transparent pricing
- Ensure you know your costs before treatment
The Bottom Line
Out-of-network doesn’t mean out-of-pocket.
At our practice:
- You get access to high-level care
- You keep your insurance benefits
- You avoid financial surprises
👉 We handle everything else.
2. Decision Tree
Step 1: Do You Have Insurance?
- Yes → Step 2
- No → Transparent self-pay options available
Step 2: Do You Have Out-of-Network Benefits?
- Yes → Step 3
- Not sure → We verify for you
- No → Step 5
Step 3: You Can Use Our Practice
Even out-of-network:
- We bill your insurance
- We manage all claims
- We handle any disputes
Step 4: Your Costs Are Protected
What You Pay:
- Deductible
- Copay
- Coinsurance
What You Don’t Pay:
- Surprise bills
- Balance bills
- Insurance shortfalls
What We Do:
If your insurer underpays, we pursue reimbursement through:
- State-level processes
- Federal arbitration under the No Surprises Act
👉 You are not involved.
Step 5: No OON Benefits?
- Clear, upfront pricing
- No hidden costs
- No surprises
Summary Box
Out-of-Network Care — Without the Risk
- We accept all plans with OON benefits
- We bill your insurance directly
- We handle all disputes
- You are not balance billed
Understanding the No Surprises Act and How It Protects You
The federal No Surprises Act, which took effect on January 1, 2022, created important protections for patients who receive out-of-network care in several common scenarios. The law prohibits surprise billing for emergency services at any facility, for non-emergency services at in-network facilities where an out-of-network provider participated without the patient’s knowledge or consent, and for air ambulance services from out-of-network providers. For patients receiving scheduled, non-emergency care from an out-of-network provider — such as an elective orthopedic procedure at an out-of-network practice — the law requires providers to deliver a good-faith cost estimate in advance and establishes a federal independent dispute resolution (IDR) process for resolving payment disputes between providers and insurers. Importantly, the IDR process takes place entirely between the provider and the insurer — patients are never directly involved in the dispute.
What “Balance Billing” Means and Why We Don’t Do It
Balance billing occurs when an out-of-network provider charges a patient the difference between the provider’s full fee and what the insurance company pays. For example, if a surgeon charges $5,000 for a procedure and the insurance company pays $2,000, a balance-billing provider might send the patient a bill for the remaining $3,000 — regardless of what the patient’s in-network cost-sharing would have been. We do not engage in this practice. Our commitment is to limit your financial responsibility to the same deductible, copay, and coinsurance you would owe for in-network care — and to pursue any additional reimbursement directly from your insurer through the appropriate dispute resolution channels.
Getting a Good-Faith Estimate Before Your Procedure
Under the No Surprises Act, uninsured patients and self-pay patients have the right to receive a good-faith estimate of expected charges before scheduling a procedure. Insured patients receiving care from out-of-network providers are entitled to an advanced explanation of benefits from their insurer. At ATX Orthopedics, we believe in proactive financial transparency for all patients. Before your procedure, our billing team will work with you to clarify your expected out-of-pocket costs, explain how we will bill your insurance, and help you understand your rights under both Texas state law and the federal No Surprises Act. Contact our office at 512-960-4590 with any questions about your coverage or expected costs.
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Written by
Orthopedic Surgeon | Hip & Knee Specialist
Dr. Sean Gallagher is a board-eligible orthopedic surgeon specializing in hip and knee replacement, ACL reconstruction, and sports medicine. He performs the majority of surgeries at Pinnacle Surgery Center of Austin. View full bio →
