Your health insurer contracts with doctors, hospitals and other providers who agree to accept the insurer’s rate as payment for their services. These are the providers in your “network.” Staying in your network usually costs you much less than going to an out- of-network provider, as you benefit from the lower rates your insurer has negotiated with network providers.
Not all plans will cover you if you go out of network. And, when you do go out of network, your share of costs will be higher. Some plans may have higher cost-sharing provisions (deductibles, copays and coinsurance) that apply to out-of-network care. For more information, see In-Network and Out-of-Network Care.
There are many reasons you may choose to go out of network even though it may cost you more. For example, maybe you have been diagnosed with a serious illness such as cancer and the doctor you select is not in your network. Maybe the condition is not serious, but you choose to pay more to see a provider you know or who has been referred to you.
In some instances, however, you may be able to go to an out-of-network provider and still pay in-network prices. Suppose you or a member of your family has a rare, serious sickness or health problem, such as a genetic disorder. Suppose no provider in your network has the training or experience to treat it the right way. In such a special, uncommon circumstance, with prior approval from your insurer, you may be able to go out of network while sharing the costs at the lower in-network rate.
This guide will discuss:
Situations When You May Need Care from an Out-of-Network Provider
There may be several situations when you may need out-of-network care and can get it at the in-network rate. These situations may depend on your plan, or on the laws in your state. For example:
Many states have laws requiring plans to cover such out-of-network services at in-network rates. If you need to go out of network, check with your insurer and follow the rules that pertain to your state and plan.
Research: Where to Go for Care
If you have a rare and serious condition, find out where you are most likely to get good treatment results. Go online and learn about what hospitals or experts specialize in this condition. Patient support groups for the condition can be a good place to start. Talk to your primary care physician (PCP) and, if necessary, to the appropriate specialist in your network. Learn as much as you can. Does it appear that you can best be treated by a provider outside your network? Then, before you go out of network, ask your insurer to cover your care at the in-network rate.
Making the Case to Your Insurer
Different insurers take different approaches to requests for out-of-network care at in-network rates. You may have to make an appeal, or a formal request, or send in a request for prior authorization. Information about the process to follow should be on your insurer’s website or in documents that describe your health plan’s benefits. Your insurer’s customer service representative should also be able to inform you about the process.
Your PCP and in-network specialist usually get the process started. They work with each other and submit the request to the insurer. Their supporting documents may include medical review of your diagnosis and the reasons why you need to go out of network. You may include a letter from the doctor from whom you seek treatment, and possibly a letter from a patient advocacy group.
Your request typically will be based on the out-of-network doctor’s training and experience, which are important to your care and different from those available in network. Experience can be subjective, with different people measuring it in different ways. The more proof you and your doctors can give, the better. For example, suppose only 200 cases of your condition happen per year in the United States. The specialist in your network may not treat even 1 of those cases per year, but the out-of-network specialist treats 12 cases per year. The 12 cases are treated successfully, with documented good results better than those your in-network specialist can show.
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 your benefits denial is reconsidered by reviewers for the insurer who were not involved in the initial decision. If your request is still denied after the internal appeals process, federal or state law may require the plan to allow you to start an “external” appeal, which means you send information about your benefits denial to an independent, outside group. Or, your insurer may waive the internal appeals process and let you go straight to an external appeal. For more information, see Appealing a Reimbursement Decision.
If your need for care is urgent, ask for an expedited appeals process. You don’t want to delay or miss out on treatment.
Taking Charge of Your Care
Your insurer has agreed to let you go out of network at the in-network rate. But, your work is not done. Usually, your out-of-network referral will be to a specific doctor. Typically, however, any doctor managing your care will work with other providers who perform related procedures. For example, one may be the radiologist who reviews your ultrasound. Another may be the anesthesiologist who puts you to sleep for surgery. There may be no in-network providers at that facility who can do the work. 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 on each of those claims. That may take time and aggravation, so it’s best that you work out those details with the insurer in advance.
Some insurers allow you to have a “global out-of-network referral.” This means that any bills from a certain hospital are processed at the in-network rate. If your insurer is not able to do that, request a case manager: one person who is your point of contact. Let the case manager know when you will be going to the hospital, and see if the insurer can put a hold on your claims until they can review all your claims at once.
Make sure you know how long your out-of-network referral is good for. Before it expires, if you still need care, ask your PCP to file another out-of-network referral. Once an out-of-network referral is approved, the insurer will usually continue to honor it.
Your Action Plan: Ask for In-Network Coverage for Your Out-of-Network Care
Do you need to go out of network? If so, follow these steps to request coverage at the in-network rate.
Most important, understand you have choices. Don’t feel obligated to use an in-network provider that you feel is unfit for your needs. You are your own best advocate. If your network can’t give you the care you need, look for out-of-network solutions—and follow all of the steps listed here to have your insurer cover your care at the in-network rate.