In and Out of Network
In-Network and Out-of-Network Care
Your plan contracts with a wide range of doctors and other practitioners, as well as hospitals, labs, radiology facilities, pharmacies and other providers. These are the providers in your “network.” Each of these providers has agreed to take your plan’s contracted rate as payment in full for services.
That contracted rate includes both your insurer’s share of the cost, and your share. Your share may be in the form of a copay, deductible or coinsurance (see cost sharing).
If you go outside your network, you will likely pay more for your care. That’s partly because providers outside your network have not agreed to any set rate with your insurer. Those providers may charge more. Another reason is that your plan may require higher copays, deductibles and coinsurance for out-of-network care. Or, they may not cover out-of-network care at all, leaving you to pay the full cost.
There are reasons why you might go out of network. If you or a loved one is facing a serious sickness, you may want more choices than you can get in your network. Or, you might go out of network by accident. That can happen if you get care from an out-of-network doc at an in-network facility.
Follow these tips to help handle your costs:
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Ask your PCP to refer you to a provider in your plan’s network.
Before scheduling a visit with a new provider, ask if he or she accepts your plan and is willing to see new patients.
Will you be having a complex procedure, like a surgery? If so, ask your doctor whether all of the providers who will join in your care are in your network.
Suppose you choose to go out of network. If so, ask the provider’s staff before your visit how much he or she will charge. Then, talk to your insurer to find out how much of the cost your plan will cover.
Is the out-of-network provider’s charge higher than your insurer’s allowed amount? If so, check the FH Consumer Cost Lookup to see what providers in your area usually charge.
Your plan may contract with doctors, dentists and other healthcare practitioners; hospitals; labs; radiology facilities; pharmacies and other types of providers. These are the providers in your “network.” Each provider has agreed to take your plan’s rate as payment in full for medical services. You can usually find a directory of your network on your plan’s website.
If you visit providers outside your plan’s network, you will likely have higher costs, for two reasons. First, these providers have not contracted with your insurer, and may charge more than what your insurer pays. Second, your plan may require higher copays, deductibles and coinsurance for out-of-network care. Often, you’ll have to pay those higher costs. You also will have to pay any difference between what your insurer pays and what the provider charges. Certain types of health plans with “closed networks,” such as an EPO, will not cover any care outside the provider network at all. This means you will have to pay the full cost yourself.
Some people may choose to see doctors outside their plans. But much more often, patients get surprised by an out-of-network bill when they thought they had only used in-network providers. This happens most often with complex services, like surgeries. In those cases, many providers are involved in your care. They may include out-of-network docs at in-network facilities.
If your insurer offers a choice of different plans, look up the network in each. Make sure you are able to get the care you need. Find out:
Are all of your current doctors in the network?
Does the network include the hospitals with which your doctors are affiliated?
How many network providers are close to where you live and work?
How much would the plan pay for out-of-network care?
Before scheduling a visit with a new provider, ask if he or she takes part in your plan. Also, ask if he or she takes part in the specific network you belong to in that plan (PPO, POS, EPO or HMO). If you choose to go out of network, ask the provider’s staff how much he or she will charge. You can see if it’s in line with other providers’ fees in your area. To do that, use the FH Consumer Cost Lookup.
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Health plans negotiate the price of medical services with certain doctors, hospitals, labs and other providers. That way, the plan, and you, pay a lower cost. These providers are in your plan’s “network.” If you visit providers who are not in your network, you may have to pay more.
Many insurers offer plans with “narrow” networks. These plans have a lower premium, but as a trade-off, your choice of providers is limited. Plans must meet certain regulations, like having enough network providers in different specialties and throughout the geographic area. There must be enough providers to deliver the benefits the plan promises its members.
Many plans sold in the health insurance marketplace have narrow networks, but some employers offer them, too. You may not even realize you are in a narrow-network plan. It’s useful to know your network, and the providers in it, to avoid high out-of-pocket costs.
You might consider a narrow network if you are young and healthy. The lower premium may balance out the smaller network if you usually only visit your doctor for regular health exams. Narrow networks can be enough if you don’t see a lot of specialists or need many medical tests.
You might need a larger network if you or a family member needs a lot of care. Suppose you have a chronic health problem like diabetes or heart disease. A narrow network could limit your choices. If you leave your network, your out-of-pocket costs could add up quickly.
Does your insurer or your job offer a choice of plans? If so, study each network with care to make sure you are able to visit your regular providers. Make sure you look at the specific network in your plan.
Search the plan’s list of providers (usually available online) by your zip code. See how many providers are close to where you live and work.
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Out-of-Network Docs at In-Network Facilities
Suppose you receive care in a hospital that is in your health plan’s provider network. You may still get a bill from providers who treated you at the hospital but are not part of your plan’s network. If you are getting surgery, out-of-network providers may include radiologists, anesthesiologists, pathologists and surgeons helping your in-network surgeon.
Your plan may not cover any out-of-network care, leaving you to pay the full cost. Or, they may cover part of the cost, but at a much lower rate than the provider charges. You may have to pay the difference.
How can you avoid getting such a “surprise” or “balance” bill? Tell your doctor in advance that you only want to use in-network providers. If your doctor has specific providers in mind, check with your insurer to make sure they are in your network. Ask your insurer what you can do to avoid being balance billed. Ask the hospital to see that any doctors assigned to your case are in your plan’s network.
If you have already been balance billed, you can try to negotiate. But, your provider is not forced to take a lower rate. New York State has special protections for consumers who are balance billed.
Most plans cover emergency care no matter where you are. They do that even if the hospital is not part of your network. But, it has to be a “true emergency,” not routine care.
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Types of Out-of-Network-Reimbursement
Most health plans have a “network,” a group of doctors, hospitals and other healthcare providers who agree to take your insurer’s rate. Some plans may not cover any services you get from providers who are not in the network. Others cover part of your care when you get services from other providers. But, plans may differ in how they decide how much they will pay out-of-network providers. Many of them develop their own “usual, customary and reasonable” (UCR) charges to help work out what they will pay out-of-network providers. Others use Medicare’s payment (fee) schedule.
UCR charges. Most plans pay for out-of-network care based on a percentage of UCR charges. Those reflect what providers typically charge for a specific procedure in a given geographic area. Health plans make their own decisions about what is usual and customary. They may use resources such as FAIR Health, however, to help them make these decisions.
Medicare fee schedules. Medicare’s payments are usually lower than payments from commercial health insurers. Some insurance plans use Medicare fees as a basis for reimbursing service for out-of-network providers. They then multiply that fee by a certain percentage to set the maximum amount that they will pay for that procedure.
The rate is often less than what your doctor charges. If you go out of network, your insurer may pay for part of the bill. You will pay the rest.
If your insurer uses the Medicare fee schedule to set its out-of-network reimbursement rates you can use the FH Medical Cost Lookup to estimate your out-of-pocket costs. Just select the “Medicare-Based” button on the right-hand side of your results page.
You may have the option to choose between plans—one that reimburses based on a percentage of UCR charges, and one that reimburses based on a percentage of Medicare fees. If so, you can compare your estimated out-of-pocket costs for services you receive out of network for both plans by using the FH Medical Cost Lookup. Select the “Compare Both” button on the right of the results page.
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When Out-of-Network Care Can Be Covered in Network
Receiving care from a provider in your health plan’s network usually costs you much less than going to an out-of-network provider. (See In-Network and Out-of-Network Care). But, you may need to go out of network for certain types of care, especially if you or a member of your family has a rare illness, such as a genetic disorder. Suppose no provider in your network has the training or experience to treat it the right way. With prior approval from your insurer, you may be able to receive the care you need out of network and still pay only the lower, in-network rate.
Different insurers take different approaches to requests for out-of-network care at in-network rates. You may have to make a formal request to your insurer, sometimes called an “appeal,” or send in a request for prior authorization. Information about the process to follow should be available from your insurer’s website, plan documents or customer service representative.
Your primary care physician (PCP) or in-network specialist typically send the initial request to the insurer. The insurer may deny your first request. But, usually you have more than one chance to get your case reviewed. You may appeal the decision “internally,” which means you can ask the insurer to reconsider your benefits denial. If your request is still denied, federal or state law may require your insurer to allow you to start an “external” appeal. That means you appeal to an independent, outside group.
If your insurer agrees to let you go out of network at the in-network rate, your out-of-network referral will usually be to a specific doctor. But, typically, any doctor managing your care will work with other providers who perform related procedures. The claim from the original doctor will be processed at the in-network rate. But, the claims from the other providers may be processed as out of network and you will have to appeal the insurer’s decision. To avoid that, it’s best that you work out those details with the insurer in advance.
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