How to Navigate Your Health Insurance Provider Network

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While staying “in-network” should be pretty straightforward, there are times when you’ll accidentally find yourself with “out-of-network” charges seemingly out of nowhere.

Have you ever been told not to see a particular doctor because they’re “not in your network” or have you ever seen “in-network” in your health insurance paperwork? Health insurance provider networks can feel elusive at times, as there is no clear way to know upfront if a doctor you visit is in-network or out-of-network. And since they affect how much you pay, they’re important to understand. If you have ever unknowingly visited an out-of-network doctor, you’re not alone. One Kaiser Family Foundation survey found that 7 in 10 individuals with out-of-network bills didn’t know their healthcare provider (doctor) was out-of-network at the time the medical service was provided.

What Is a Health Insurance Provider Network?

“In-Network”: Health insurance companies contract with doctors offices and hospitals to receive a special rate for their services. The doctor’s office charges a certain amount per service and applies a discount according to the contract it has with your health insurance plan. The doctors and hospitals that your plan has contracted with are considered “in-network.”

“Out-of-Network”: If a doctor or hospital is not contracted with your health insurance plan then they are “out-of-network” and there is no discount applied to the service you received from that provider. Often, health insurance plans also try to discourage members from going out-of-network by charging them higher copays, coinsurance, and deductibles.

Out-of-Network Costs: Either Partially Covered or Not Covered at All

How your plan pays for out-of-network services depends on what type of health insurance plan you have.

HMO & EPO: If your health insurance plan is provided by a Health Maintenance Organization (HMO) or an Exclusive Provider Organization (EPO) then your plan does not pay for any services with providers that are out-of-network.

PPO & POS: If your health insurance plan is provided by a Preferred Provider Organization (PPO) or is a Point-of-Services (POS) plan, then your plan does pay for some of the service costs from out-of-network doctors – but you must share some of the costs (often, your portion of the cost-sharing is higher).

As an example, let’s say you’re visiting a dermatologist to have a cyst removed and you’re on a PPO plan. Below is a comparison of what the charges would look like depending on if the provider was in-network or out-of-network.

Accidentally Going Out-of-Network

Have you ever gotten treatment, checking ahead of time that the treatment would be considered in-network, but in the end find yourself with out-of-network charges? How does this end up happening, though?

Scenario 1: Let’s say you’re having a surgery performed. Before agreeing to the surgery, you check that the surgeon and the hospital are in-network – you’re seemingly covered. But maybe you forgot to take into account the anesthesiologist who’ll also be essential to your surgery. It probably didn’t occur to you until later that the anesthesiologist is actually outside your health insurance provider network. In this case, unknowingly to you, you’re going to be charged more for that anesthesiologist’s bill because they’re out-of-network. Unfortunately, there isn’t a lot you can do in this situation. If this happens, you could try to work out an arrangement with your health insurance company.

Scenario 2: In a different scenario, doctors can sometimes refer patients to specialists or other doctors that are out-of-network. Before being referred, check to make sure the provider is in your network. If they aren’t, call you doctor back and ask for a referral to a provider within your network.

When Should You Go Out-of-Network?

While staying within the boundaries of your network sounds tricky, they’re usually set up so that you won’t have a reason to go out-of-network. Doctors of all types and specialties are included so you should never find yourself unable to get the services you need from inside your own health insurance provider network.

That being said, in the rare case when you can’t find an in-network provider, health insurance plans will review the medical necessity of the situation and potentially make an exception or try to contract with the doctor to bring them in-network.

In the case of emergencies, most plans will cover you if you have to see an out-of-network provider. However, there have been cases where patients get charged exorbitantly when they have to receive a service out-of-network. It’s best to refer to your plan’s specific rules regarding this situation.

Out-of-Network Charge and Balance Billing

The Affordable Care Act (Obamacare) prohibits insurance companies from charging higher cost-sharing for out-of-network services in cases of emergencies. However, it doesn’t prevent the hospital from billing patients directly.

“Balance billing” happens when your health insurance company bills you the difference between what the health insurance company pays and what the hospital charges. Since the hospital is out-of-network and there is no contract between that hospital and your health insurance company, hospitals can go directly to patients to recoup their costs.

Some states are trying to provide more protection to patients by restricting hospitals from balance billing patients. New York has created legislation prohibiting individuals on plans that are state-regulated from being balanced billed.

Medical bills, in general, aren’t fun to receive. Receiving an additional charge because you unknowingly went to a doctor that is out of your network just adds insult to injury. Always check with your insurance provider before visiting a new doctor, if you can.

Rachael Forster: Rachael is a regular contributor to HealthCare.com. She's a health and wellness writer who is passionate about healthcare policy, yoga, and travel. She lives in Chicago.

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