In-network vs. out-of-network providers: What it means for your wallet

Do you know what type of coverage is available to you with your health plan? Here’s a closer look.

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.” Whatever the 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.

Need to figure out which health plans have in-network coverage for your doctors? Explore your options online, or call a licensed insurance agent at 1-844-211-7730 for more information.

What’s the difference between in-network and out-of-network providers?

A provider network is a list of the doctors, health care 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 plan, they are known as an “out-of-network provider.”

It’s a good idea, before you sign up for a health insurance plan, to make a list of all the providers and health care facilities that you use. This way, you can try to make sure that all of them are in your new plan’s network. Your provider list may include:

Doctors
Hospitals
Pharmacies
Physical therapists
Psychologists, psychiatrists and other mental health care professionals
Urgent care clinics

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. Here are some ways to keep costs down:

See if the provider will offer a discount. Recently, 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 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.)

Shopping around for a health plan? Learn the type of networks and benefits available by entering your ZIP code to search available plans or by calling a licensed insurance agent at 1-844-211-7730.

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.

What happens if I go out of network for emergency care?

Legally, plans aren’t allowed to charge you for out-of-network cost sharing, 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 or coinsurance is a fixed price you pay for health care services, while your deductible is what you pay out of pocket before your insurance pays the rest.)