What does it mean when insurance is out of network

As health insurance plans change and options vary, the same holds true for providers and health care facilities. Although there may be more treatment alternatives for patients available now, that doesn’t necessarily translate into more treatments covered. Because out-of-network costs add up quickly, it is important you become familiar with your plan and whether your health care provider is in your network.

You can be charged with out-of-network costs when care is provided and the medical provider has not agreed to a negotiated fee with your insurance provider. This means medical providers may charge the full amount for your treatment and your insurance provider may not pay for these charges, leaving the full burden of payment up to you. Avoid being surprised by costs associated with out-of-network fees by educating yourself on your plans limitations and additional payment options.

Maximize insurance benefits by reading and understanding your plans language. By becoming familiar with your plans benefits and limitations, you’ll be able to make better healthcare decisions for yourself. If you have questions about your plan, ask your insurance provider or Human Resources manager.

If the provider you use is out-of-network, determine whether the same service is available within your network. If you are comfortable switching doctors to lower healthcare costs, this might be an additional cost-saving option for you. Additionally, if you are thinking about switching plans and see a certain provider regularly, be sure to determine whether they are in the network. If your plan does not satisfy your healthcare needs, explore alternative plans during open enrollment period.

Another way to help offset costs is to inquire through your treating hospital, facility or provider about assistance programs. Usually facilities have programs that will help with some of the financial burden. There are also state drug assistance programs available through your state commissioner’s office. There are also co-pay assistance programs available nationally and for disease specified programs.

Explore discount drug options with large retailers, supermarkets or pharmacy chains. Different dispensers have different co-pays. Shop around to ensure you are getting the best deal for your prescription.

Utilize resources that provide “cost calculator” for common procedures. Your medical costs may vary depending on what state you live in. Using a cost calculator will help lead you to a ball park estimate of about what things should cost. This can be especially useful if you are uninsured. You can access a Medical Cost Calculator courtesy of Fair Health http://fairhealthconsumer.org/medicalcostlookup.php. Fair Health is an independent, non-profit organization whose mission is to provide patients with a clear, unbiased explanation of the medical reimbursement process.

Be picky. When choosing a healthcare plan, be diligent about choosing doctors and services within your plan. Before care, ask whether the doctor is in your network. Additionally, if your doctor advises additional treatment like a blood test, don’t assume that it is covered. For every new element of care introduced, ask whether it is in network.

One of the best things you can do to help keep tabs on your healthcare bills is to take good, thorough notes. Some things to consider when organizing your paperwork include asking:
1. What is my financial responsibility?
2. What is my OON deductible?
3. What is my OON cost share (the percent you are responsible for)?
4. Are there above Usual, Customary, and Reasonable Charges (UCR)?
5. What is my out-of-pocket maximum?

The most important thing to remember when tackling out-of-network costs is to educate yourself about your plan and ask questions! By keeping an open line of communication with your healthcare providers and your insurance providers, you’ll be able to help avoid surprises and make the best healthcare decisions for you.

You go for a routine appointment at a new doctor and—BAM! You’re hit with a larger than expected bill even with your health insurance coverage. You find out this high price is because the healthcare provider you used is out-of-network. But what does that mean? Let’s find out!

What does out-of-network mean?

Out-of-network describes a physician, hospital, or healthcare facility that is not a part of your health insurance company’s provider network. This means that your insurance hasn’t pre-negotiated a network rate with that physician, hospital, or facility, and you will be charged a larger percentage of the total medical bill or for the entire bill, depending on your particular health plan.

All managed health plans have a network, including Medicaid and Medicare.

Another blow from using an out-of-network provider is that typically these costs are not applied to your deductible if your plan does not cover out-of-network costs. They won’t count toward your out-of-pocket maximum either. 

Let’s break this down when comparing out-of-network to in-network.

In-network vs. out-of-network

When you sign up for a healthcare plan, the insurance company provides you with a list of doctors, hospitals, and healthcare facilities that are in-network. Visiting in-network providers for healthcare services will mean lower rates from as the insurance company and provider have negotiated rates. Unless your insurance company offers a generous out-of-network benefit, visiting out-of-network providers will mean your medical care expenses will increase as your insurance company will cover less or nothing at all.

For example, you see your primary care provider because your sinuses hurt. She takes a look and recommends that you see a specialist. The total charge for that trip to the doctor is $100. Since she’s in-network, a discount is applied to the total bill since your insurance has pre-negotiated a rate with that doctor. Let’s say, the discounted total is now $80. You could be responsible for the remainder of the bill depending on your coinsurance and copay.

However, after doing some research, you realize that the conveniently-located specialist you need to see is out-of-network. You decide to take the risk and book an appointment. A few weeks after the visit, you get a bill for $250. Since that specialist wasn’t in-network, no discount is applied to the total medical bill, and your insurance company either covers less, or worse, nothing at all since the provider was out-of-network and copays and coinsurance won’t apply. 

To see in- and out-of-network costs comparisons in your area, this calculator can help. It is often better to use an in-network healthcare provider, if possible, since the costs will be lower.

It is also important to note that there are typically differences in cost between health insurance plans when dealing with in-network and out-of-network fees.

• PPO stands for Preferred Provider Organization. These types of plans typically offer out-of-network benefits—although, they’re not as good as in-network benefits. The insurance company will help pay a portion of the bill and you will likely pay a larger portion of the coinsurance. 
• HMO is short for Health Maintenance Organization. These types of plans typically don’t offer any out-of-network benefits—which means you will have to cover all out-of-network costs out of pocket. 
• EPO (or Exclusive Provider Organization) is a type of health plan that only covers in-network services (except in an emergency).
• POS (aka Point of Service) is a plan that requires policyholders to get a referral from their primary care doctor in order to see a specialist. You’ll save money by using in-network providers, but unlike an HMO, you may receive care from an out-of-network provider.

Another exception to in-network vs. out-of-network costs is emergency services. Insurance companies cannot penalize you with higher copayments and coinsurance if you require emergency care from an out-of-network hospital. You also are not required to get pre-approval for emergency room services for out-of-network doctors and hospitals. However, If the out-of-network emergency room doesn’t have a contract with the insurance company, it is not obligated to accept their payment as payment in full. If they pay an amount less than the out-of-network emergency room bills, the emergency room can send the consumer a balance bill for the unpaid amount.

What do I do if my doctor is out of network?

Let’s say you’ve been visiting the same gynecologist for 10 years, but after starting a new job and changing your insurance, she becomes an out-of-network provider. You may no longer be able to visit her because you can’t afford the extra healthcare costs.

It will more likely be cheaper to change to a doctor who is in-network. However, if you do not want to leave your current doctor, talk to him or her to see if there are any options. Some doctors allow patients to pay the cash price, which can be cheaper than what insurance companies offer when compared to out-of-network prices—but it won’t count toward your deductible or out-of-pocket maximum.

You can also ask your health insurer for a network gap extension, where your insurance will cover the doctor as if they are in-network. However, these are typically only awarded for special circumstances, such as no other doctor in that specialty in that area, as it loses the health insurance companies’ money. 

Out-of-network alternatives

Out-of-network care benefits are costly. In some cases, it may be better to shop around for a new insurance plan with better in-network coverage during open enrollment or a Special Enrollment Period for major life events. 

One of the easiest ways to lower healthcare expenses is to use SingleCare to subsidize medication costs while you’re underinsured. Simply search for your medication and find the cheapest prices available, with or without insurance.

What is the difference between in network and out of network?

What is the difference between out of pocket and out of network?

How do I get out of network?