Medical providers are considered out-of-network when they do not have a contract with your insurance company. This type of care is typically more expensive than in-network care.
Depending on the plan design, out-of-network charges may not be applied toward your deductible or out-of-pocket maximum. This can lead to surprise balance bills.
Access to Specialists
Healthcare providers with contracts with your insurance company are known as “in-network.” These doctors and facilities have agreed to accept payments from your insurer at a discounted rate, saving you money.
When you receive health care outside your insurance network, your health plan might still pay for it, but you will likely be responsible for a larger share of the costs. This is called a balance bill.
In the United States, 30 million people lack access to specialty care due to cost or coverage issues. Safety net clinics and federally qualified health centers are essential for meeting basic primary care needs. Still, many patients needing specialized services require a referral from their doctor or travel long distances to see a specialist.
As a result, some people miss out on potentially life-saving treatment. Others turn to emergency departments instead, which can be even more expensive than seeing a specialist. And those who can access specialty care often face barriers like cost and scheduling issues.
For these reasons, having a health insurance policy that includes out-of-network insurance is helpful. If you have a rare condition or want to stay with a doctor you like, ask your insurance carrier about out-of-network coverage options. You can do this by calling your insurance company or asking your doctor to submit a formal request to the insurance company for an out-of-network exception.
A significant benefit of having out-of-network insurance is that it can help you get health care at a lower cost. This is because when you see doctors and facilities that aren’t in your plan’s network, you have to pay the difference between what the provider charges and your insurance company’s negotiated rate for that service.
While this is generally more expensive than seeing in-network providers, it can still be a good option for many people. For example, suppose you have a rare medical condition that only a few doctors or facilities in your area can treat. Suppose you have a doctor outside your network with the expertise and training to treat your specific condition. In that case, it might be worth getting a plan with out-of-network coverage to receive treatment from that provider.
Out-of-network insurance can also be a good option for people who want to maximize their choices when choosing their healthcare providers. You can check if your doctors are in-network or out-of-network by checking their website or calling their office. You can also discover how much they charge for different services by shopping around or asking your insurer.
If you want to go out-of-network, it’s essential to ask your doctor or hospital to provide a cost estimate before you receive the services. Most healthcare providers have no problem providing you with this information, and they may even be willing to work out a payment plan with you.
It’s best to stay within your insurance network whenever possible. But there are times when going out-of-network is necessary or even desirable.
In-network providers have signed contracts directly with your insurance company that limits how much they can charge for their services. That’s why it’s essential to find out if your doctor or healthcare provider is in-network before making an appointment with them. You can do this by looking at your provider’s online directory or calling them directly. You can also check your health insurance’s website or review your policy documents to see their rates for out-of-network care.
When a healthcare provider isn’t in-network, they generally charge higher fees than in-network doctors. But you want to continue seeing your healthcare provider, and they are an expert in treating your specific health condition. In that case, you can request that your insurance carrier cover their out-of-network charges at in-network rates. This is known as requesting prior authorization.
Different insurers have different processes for granting or denying requests for out-of-network coverage, so it’s essential to know the details of your policy. But suppose your healthcare provider refuses to be part of your insurance network, and you’re determined to see them anyway. Many healthcare providers are willing to help make it affordable by working out a payment plan.
Sometimes, your health insurance might cover out-of-network care as if it were in-network. This could save you a lot of money in the long run, especially for non-emergency care. You can request this coverage from your health insurance company by explaining why using an in-network provider won’t work.
Indeed, understanding the cost breakdown for out-of-network care is crucial for individuals seeking medical treatment, and it can vary significantly depending on the specific health plan and policy type. Health Estimates is a health insurance brokerage that can help individuals and families navigate these complexities by providing estimates and information related to healthcare costs.
In addition, certain situations require you to use an out-of-network provider, like when your provider drops from your health insurance network or chooses to leave. If this is the case, consider negotiating a contract with your out-of-network provider for a single episode of care at a negotiated rate. If you cannot agree with the provider, the law requires them to balance bill you for the difference between what your health plan agreed to pay and their full charges for that service. This is a common source of surprise medical bills and is something you should avoid.