in practice, they just make you sign a notice and consent form in order to receive care. if all the local hospitals do this (and they do) then you no longer have any option but to sign the form.

we really need to eliminate this absolutely ludicrous distinction legislatively.

EDIT: i stand corrected with regard to anesthesiologists. I maintain that hospitals and providers are quickly learning how to maneuver patients into scenarios where they will be subjected to surprise billing anyway. I also maintain that the concept of out-of-network services is mostly ridiculous, since the median patient is very rarely in a position to make actual choices about most of the care they receive.