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My surgery was at an in-network hospital, but the anesthesiologist was out of network and sent me a separate bill. Do I owe it?

Health insuranceWho paysTexasChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: Texas Insurance Code · Chapter 1301 · § 1301.164(b) «Out-of-Network Facility-Based Providers» View original ↗

In short

  1. Texas makes the insurer pay that doctor, not you [1].
  2. You owe only your copayment, coinsurance and deductible [2].
  3. There is one way out of that, and you had to sign for it [3].

What this means

Texas wrote a rule for this exact bill. It uses the term facility-based provider. That means a doctor or provider who treats patients of a health care facility [5]. Was the facility a preferred provider in your plan? Then your insurer must pay the covered service. It pays at the usual and customary rate, or at an agreed rate [1]. The law also says who gets the money. The insurer must pay that provider directly [1]. The deadline is the 30th day after a clean electronic claim. For a clean claim on paper it is the 45th day [1].

Now the part that answers your question. An out-of-network facility-based provider may not bill you more than your copayment, coinsurance and deductible [2]. The law adds that you do not have financial responsibility above that amount [2]. The same bar covers a person asserting a claim as an agent or assignee of that provider [2]. Your share is based on the amount the insurer first determined payable [2]. If its internal appeal changed that, the changed amount is used [2]. And it may not be based on any additional amount owed to the provider under Chapter 1467 [2].

There is one carve-out, and it is narrow in its own words. The section does not apply to a nonemergency service that you elect in writing, in advance, for each out-of-network provider [3]. And before the service, that provider must give you a complete written disclosure [3]. The disclosure must explain that the provider has no contract with your plan [3]. It must give projected amounts you may be responsible for [3]. And it must say the circumstances under which you would owe those amounts [3].

Your own paperwork carries these numbers. For care by an out-of-network provider, your plan must put a notice in the explanation of benefits [4]. That notice must state the billing prohibition that applies [4]. It must also give the total that provider may bill you [4]. Your copayments, coinsurance, deductibles and other amounts must be itemized in that total [4]. These sections are the ones for a preferred provider benefit plan [1]. These sources do not say what applies to an HMO, or to a self-funded plan at work.

Your next step

Find the billing prohibition statement on your explanation of benefits, and the total that provider may bill you [4]. Compare that total with the bill. Then confirm the hospital was a preferred provider on that date [1]. Then look for a written election naming that provider, and for a written disclosure with projected amounts [3]. Ask the insurer in writing for the amount it determined payable, and for the date it paid the provider [1]. The sources give no deadline for your own letter. The dates they do give are the insurer's. It must pay by the 30th day after a clean electronic claim, or by the 45th day after a clean claim on paper [1].

Check it yourself

Check that the hospital was a preferred provider in your plan on that date [1]. Then find the billing prohibition statement on your EOB [4]. Find the total you may be billed there as well [4]. Then look through your pre-surgery papers. Look for a written election naming that provider, and for a disclosure with projected amounts [3]. Would a signed form you cannot find meet that test? "Don't know yet" here, so ask for a copy of anything you signed.

Where this comes from (5)

  1. [1] Texas Insurance Code · Chapter 1301 · § 1301.164(b) «Out-of-Network Facility-Based Providers» · checked 2026-11-06

    an insurer shall pay for a covered medical care or health care service performed for or a covered supply related to that service provided to an insured by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a preferred provider. The insurer shall make a payment required by this subsecti…

  2. [2] Texas Insurance Code · Chapter 1301 · § 1301.164(c) «Out-of-Network Facility-Based Providers» · checked 2026-11-06

    an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured receiving a medical care or health care service or supply described by Subsection (b) in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's preferred provider b…

  3. [3] Texas Insurance Code · Chapter 1301 · § 1301.164(d) «Out-of-Network Facility-Based Providers» · checked 2026-11-06

    This section does not apply to a nonemergency health care or medical service: (1) that an insured elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and (2) for which an out-of-network provider, before providing the service, provides a complete written disclosure to the insured that: (A) explains that the provider does not have a contract with th…

  4. [4] Texas Insurance Code · Chapter 1301 · § 1301.010(a) «Balance Billing Prohibition Notice» · checked 2026-11-06

    An insurer shall provide written notice in accordance with this section in an explanation of benefits provided to the insured and the physician or health care provider in connection with a medical care or health care service or supply provided by an out-of-network provider. The notice must include: (1) a statement of the billing prohibition under Section 1301.0053 , 1301.155 , 1301.164 , or 1301.165 , as applicable; …

  5. [5] Texas Insurance Code · Chapter 1301 · § 1301.164(a) «Out-of-Network Facility-Based Providers» · checked 2026-11-06

    In this section, "facility-based provider" means a physician or health care provider who provides medical care or health care services to patients of a health care facility.

How we found this

We matched your question to 5 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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