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Importance Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills (“surprise bills”) from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. Objective To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Design, Setting, and Participants Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network …