Not sure why some doctors take your insurance and others don’t? It all comes down to whether the providers you want to see are “in network” or “out of network.”
In some cases, you may have access to a wide range of in-network providers in your area. But in others, the providers that are the most convenient distance away might be out of network.
Whatever your situation, deciding to go out of the network can be a big decision that may end up being pricey, according to Adria Gross. She’s the founder of MedWise Insurance Advocacy in Monroe, New York.
Here are some things to keep in mind when thinking about accepting in-network and out-of-network care.
Have a high deductible or out-of-network costs? Fixed benefit health insurance might be able to help.
What’s the difference between in-network and out-of-network providers?
A provider network is a list of the doctors, healthcare providers and hospitals that an insurance plan contracts with to provide medical care to its members for agreed upon prices. Providers who accept these contracts are called “in-network providers.” If a provider isn’t under contract with your health insurance plan, they are known as an “out-of-network provider.”
It’s a good idea, before you apply for a health insurance plan, to make a list of all the providers and healthcare facilities that you use. This way, you can try to make sure that all of them are in your new health insurance plan’s network. Your provider list may include:
- Psychologists, psychiatrists and other mental health professionals
If you do go out of the network, keep in mind that the costs can add up. It’s not just that an out-of-network provider is more expensive. They may also operate out of an out-of-network facility, such as a hospital or outpatient center where they perform surgeries, notes Michael Orefice, senior vice president of operations at SmartFinancial. And that could be even more expensive.
Out-of-network providers may also work with out-of-network labs. “If you choose an out-of-network provider or hospital, all of the services and providers might also be out of network, which can become very expensive and possibly unaffordable,” points out Gross.
What happens if I have to go out of the network?
Sometimes, you may feel that you have no choice but to use an out-of-network provider. For example, you could live in a rural area where the closest in-network provider is miles away. Or you might’ve been comfortable going to a provider, then you switched health insurance plans, and now they’re out of network. But you still want to see them.
Regardless of your personal situation, here are some ways to try and help keep costs down:
- See if the provider will offer a discount. Gross had a client whose son needed surgery with an out-of-network provider. “I spoke to the doctor’s staff, and the doctor agreed to a discount if the family paid in advance,” says Gross. “Sometimes, this is the best way to go if a physician doesn’t take insurance. They’ll often be more flexible if you pay in advance.”
- Select a health insurance plan that offers out-of-network benefits. Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) rarely cover out-of-network providers unless it’s an emergency visit, notes Orefice. But a Preferred Provider Organization (PPO) or Point of Service (POS) plan may pay for part of the cost. Just keep in mind that they won’t pay as much as they would for an in-network provider, and the deductible will be higher, Orefice notes.
Also, many health insurance plans don’t credit your out-of-network visits and services toward your out-of-pocket maximum. (That’s the most you’d have to pay out of pocket during a plan year.)
Dealing with out-of-network costs? A fixed benefit health insurance plan may help provide benefits that your primary plan might not cover. Learn more.
- Appeal to your insurance company. Start by talking to your primary care provider (PCP) or in-network specialist, advises Orefice. They may be able to work with you to convince your insurance company that you need to see an out-of-network provider. “If it’s medically necessary for you to go out of network, chances are you’ll be covered for part or all of the bill,” he explains. Your PCP can help provide the verification you need to see a certain out-of-network physician.
Just keep in mind that your insurance may only pay the amount that they normally pay to a contracted specialist for the visit or treatment, leaving you with the balance.
You can always appeal the denial of out-of-network coverage to your insurance company, says Orefice.
- Choose a fixed indemnity plan. An additional option would be to buy a type of supplemental insurance called a fixed indemnity plan. There is a monthly premium for supplemental insurance that is not included in what you’d pay for your primary health insurance. Fixed indemnity insurance pays a fixed amount for covered health services.
For example, a fixed benefit health insurance plan pays preset benefits for specified services like hospital stays, surgical services, emergency room visits and diagnostic tests. These plans may provide help with things like high deductibles and out-of-pocket expenses from other health insurance. These plans could also help with medical bills for out-of-network care. (You might also see this type of plan called fixed indemnity.) Some of these plans may be limited to hospital benefits and you may hear them called hospital indemnity insurance.
What happens if I go out of network for emergency care?
Legally, plans aren’t allowed to charge you for out-of-network penalties, such as out-of-network coinsurance or copayments, for emergency services as defined by your plan’s documents. You’ll still have to pay a copayment or coinsurance, as well as potentially a deductible, but at an in-network rate. (A copayment is a fixed price you pay up front for certain health care services, while your deductible is what you pay out of pocket before your insurance starts paying. Coinsurance is the share you have to pay after you have paid your deductible.)
A hospital stay or surgery may lead to unexpected medical bills. Learn how fixed benefit health insurance can help, or call a licensed insurance agent at 1-844-211-7730 to discuss your options.
For informational purposes only. This information is compiled by UnitedHealthcare, and/or one of its affiliates, and does not diagnose problems or recommend specific treatment. Services and medical technologies referenced herein may not be covered under your plan. Please consult directly with your primary care physician if you need medical advice.
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