Pulmonologist surprise bills occur when a respiratory specialist bills your insurance as out-of-network even though you received care at an in-network hospital. This happens because hospitals and the doctors who work in them maintain separate contracts with insurers, and a pulmonologist may not be part of your plan's network at that facility. About 1 in 7 patients who are admitted to in-network hospitals encounter at least one out-of-network specialist bill, according to the Health Care Cost Institute's analysis of 2016 employer claims.
Federal protections enacted in 2022 reduce the financial surprise for many patients, but gaps remain. Pulmonologists performing diagnostic procedures like sleep studies, bronchoscopies, and pulmonary function tests are common sources of these bills because the provider bills separately from the facility—and each party may or may not accept your insurance. Understanding which scenarios your insurance covers, what you actually owe, and how to prevent surprise bills protects you before the invoice arrives.
Table of Contents
- Why pulmonologists bill separately from hospitals
- Which pulmonary procedures carry the highest surprise-bill risk
- What the No Surprises Act covers and where it stops
- What you are actually required to pay
- Steps to prevent a surprise bill
- Frequently Asked Questions
Why pulmonologists bill separately from hospitals
Your hospital and its doctors are not one billing entity. Ancillary specialists like pulmonologists can bill out-of-network even at in-network facilities, according to the Kaiser Family Foundation's guide to the federal No Surprises Act. This happens because the pulmonologist may practice independently, work for a separate medical group, or maintain their own insurance contracts.
The hospital's contract with your insurer does not bind the specialists who work there. The billing separation exists even when the pulmonologist works full-time at that hospital. Your hospital may be in-network, the facility fee may be covered, but the pulmonologist's interpretation or procedure fee goes to a separate account and may be routed through a different billing system. This is not always visible to you when you schedule the appointment.
Which pulmonary procedures carry the highest surprise-bill risk
Diagnostic and therapeutic procedures—including sleep studies, bronchoscopies, and pulmonary function tests—are where pulmonologist surprise bills commonly occur, according to Blue Cross Blue Shield provider documentation. Each of these procedures typically involves both a facility fee (the cost of using the hospital's equipment and space) and a professional fee (the pulmonologist's interpretation and medical judgment).
Either one can be billed out-of-network. A sleep study exemplifies the risk: the facility bills for the overnight monitoring equipment and room, and the pulmonologist bills separately for reading and interpreting the results. If the pulmonologist is not in-network, you receive two bills—one in-network and one out-of-network—even though the entire procedure happened in one place. Bronchoscopies (where a tube is passed into the airways) and pulmonary function tests (breathing measurements) follow the same billing structure.
What the No Surprises Act covers and where it stops
The federal No Surprises Act, which took effect in 2022, protects against surprise bills for most emergency services and certain non-emergency care at in-network facilities. However, the law contains exemptions. Ancillary diagnostic services—the category that includes pulmonary function tests and sleep-study interpretation—receive limited federal protection, meaning some surprise bills from pulmonologists may not be covered by the federal rule.
Additionally, enforcement of the No Surprises Act has been incomplete as of mid-2026, with health plans reportedly delaying or refusing to pay independent dispute resolution (IDR) awards in the physician's favor. The law does not apply to Medicare, Medicaid, or all self-insured employer plans in certain states. These gaps mean that protections vary significantly depending on your type of insurance and where you live.
What you are actually required to pay
If your pulmonologist's surprise bill qualifies for federal protection, you are responsible only for your plan's in-network cost-sharing—your copay, coinsurance, or deductible—not the full out-of-network balance. Payment disputes between your insurance company and the pulmonologist are resolved through independent dispute resolution (IDR), a process where a neutral third party decides how much the provider receives.
The provider and insurer argue their positions; you do not participate. The key phrase is "if your bill qualifies." Diagnostic procedures and certain non-emergency services have narrower protection than emergency care. If your bill does not qualify, you may receive a balance bill for amounts your insurance refused to pay. Never assume you are protected—verify before the procedure.
Steps to prevent a surprise bill
Before any diagnostic or therapeutic pulmonary procedure, take these steps: If you receive a surprise bill after the fact, send a written dispute to your insurance company within the timeframe specified in your policy. Reference the No Surprises Act protections if you believe your bill qualifies, and include copies of your good-faith estimates and written network confirmations.
- **Verify network status in writing.** Call your insurance company and ask whether the pulmonologist and the specific facility are both in-network. Do not rely on verbal assurance; ask for written confirmation.
- **Request a good-faith estimate from both the facility and the pulmonologist.** The federal rule requires providers to give you a written estimate if you ask. Separate estimates for the facility and the pulmonologist will show you whether both are in-network.
- **Ask specifically about separate billing.** Request clarification about whether anesthesia, lab interpretation, or other services will be billed by a separate entity. Get the name and network status of whoever will bill you for each component.
- **Confirm nothing has changed the day before the procedure.** Network status and billing arrangements can shift; a brief confirmation call prevents a bill that was predictable but went unverified.
Frequently Asked Questions
Can a pulmonologist bill me out-of-network if I went to an in-network hospital?
Yes. Hospitals and doctors maintain separate insurance contracts. An in-network hospital does not mean the pulmonologist who works there is in-network, so you can receive an out-of-network bill even though the entire procedure happened in-network.
What percentage of in-network hospital visits include an out-of-network specialist bill?
Approximately 1 in 7 in-network hospital admissions include at least one out-of-network professional bill, according to Health Care Cost Institute data.
Does the federal No Surprises Act protect me from all pulmonologist surprise bills?
No. The act protects against surprise bills in most emergency and some non-emergency scenarios at in-network facilities, but ancillary diagnostic services—including pulmonary function tests and sleep-study interpretation—have narrower protection. Protections also vary by insurance type and state.
What do I pay if I receive a surprise pulmonologist bill?
If your bill qualifies for federal protection, you owe only your plan's in-network cost-sharing (copay, coinsurance, or deductible). Disputes between your insurer and the provider are resolved through independent dispute resolution; you cannot be billed for the balance if the law applies.