Out-of-Network Surgery Balance Billing Calculator

Understand how much cash you will owe when an out-of-network surgery is only partially reimbursed. Combine the billed charge, your plan’s allowed amount, coinsurance, and any deductible or out-of-pocket cap to surface insurer payments, balance billing exposure, and the total you must budget.

Total billed amount from the surgeon, facility, or anesthesiologist.
What your insurer considers reasonable and customary for the service.
Percentage of the allowed amount you owe after the deductible.
Optional. Enter any unmet deductible that applies to out-of-network claims.
Optional. Leave blank if your plan does not cap out-of-network spend; otherwise enter remaining OOP headroom.

Balance billing rules vary by state and plan; confirm coverage determinations directly with your insurer before paying invoices.

Examples

  • $48,000 billed, $22,000 allowed, 40% coinsurance, $4,000 deductible, $9,100 OOP cap ⇒ Allowed amount: $22,000.00 USD • Patient responsibility on allowed charges: $9,100.00 USD (41.36% of allowed after $4,000.00 deductible and 40.00% coinsurance). Balance bill exposure: $26,000.00 USD. Estimated insurer payment: $12,900.00 USD. Total patient responsibility including balance bill: $35,100.00 USD. Out-of-pocket maximum reached on allowed charges; amounts above the cap are assumed covered.
  • $32,500 billed, $15,000 allowed, 30% coinsurance, $12,000 deductible, no cap entered ⇒ Allowed amount: $15,000.00 USD • Patient responsibility on allowed charges: $12,900.00 USD (86.00% of allowed after $12,000.00 deductible and 30.00% coinsurance). Balance bill exposure: $17,500.00 USD. Estimated insurer payment: $2,100.00 USD. Total patient responsibility including balance bill: $30,400.00 USD.

FAQ

Does this account for separate facility and professional bills?

Run the calculator for each provider and add the totals together. Hospitals, surgeons, and anesthesiologists often submit separate claims with different allowed amounts.

How should I include surprise billing protections?

If your procedure qualifies for No Surprises Act protections, replace the provider charge with the qualifying payment amount (QPA) so balance billing is limited to that benchmark.

Can I model an insurer's exception review or negotiation?

Yes. Adjust the allowed amount to the higher figure your plan agrees to after negotiations so the calculator reflects the revised reimbursement and lower balance bill.

What about multiple deductibles (individual vs. family)?

Enter the remaining deductible that applies to this claim. If both individual and family deductibles are in play, use the larger remaining amount to avoid underestimating your out-of-pocket cost.

Additional Information

  • Allowed amount reflects plan-specific usual and customary data; balance bills arise when providers charge more than that figure.
  • Out-of-pocket caps often exclude out-of-network balance bills—enter the cap only if your plan explicitly applies it.
  • Deductible entries are limited to the allowed amount so you do not overstate the patient share.

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