Out of Network Providers: 5 Things to Know Before You Go

What happens if you need out-of-network providers for medical care? It happens.

Maybe you need to see a specialist who isn’t in your plan’s network.
Maybe you have established relationships with out-of-network healthcare providers.
Maybe it’s logistically more convenient to see out-out-of-network providers.
- For example: You’re in the process of moving. Your health plan recently changed. Or you’re on vacation when you need care, and out-of-network-providers are your only option.

These are just a few common reasons you might need out-of-network providers.

So, what happens if you need medical care and go with out-of-network providers? Here are 5 things to know before you go.

1. Know the Difference Between In-Network & Out-of-Network Providers

The term ‘network’ doesn’t just refer to your office computers. Your insurance company also has a network:

A network is a group of healthcare providers it contracts to provide you service.
In-network providers (which include doctors, nurses, labs, specialists, hospitals, and pharmacies) agree to charge rates that are determined by your insurance company.
When you use in-network providers, you pay a set part of the total bill: your copayment or coinsurance.

Out-of-network providers are a different story:

They have not agreed to a contract with your insurance company and may charge higher rates for the same services.
However, this doesn’t mean your insurance company will pay these higher rates.
If your insurance company provides out-of-network coverage, it may only pay the amount it would for an in-network service. As a result, you could owe a greater percentage of your care in the form of higher copayments and coinsurance when you go to out-of-network providers.

2. Understand Copays: In vs. Out

Let’s look at some examples of a copay for in-network care vs. a copay for care from out-of-network providers.

The In-network Copay

Let’s say, for instance, that your in-network doctor has contracted with your insurance company.

They agree to charge $200 for a simple office visit.
Your insurance company has agreed to pay $170 for that office visit.
Your copayment will be the remaining $30.

Here’s what typical copays are for in-network care.¹

Doctor’s visit: $15 to $25
Specialist’s visit: $30 to $50
Urgent care: $75 to $100
Emergency-room visit: $200 to $300

The Out-of-network Copay

However, consider the out-of-network doctor who has not made this contract with your insurance company.

This doctor charges $300 for the same office visit.
Your insurance company still pays $170.
This means you would pay the difference: $130.

Note: In this example, you could pay an estimated $130 more for the exact same care from out-of-network providers.

2.5 Get Clear on Coinsurance Costs: In vs. Out

Sometimes, what you pay for medical care depends on the coinsurance agreement your health plan has with in-network providers. And it’s different for out-of-network providers. Here are two examples.

The In-network Coinsurance Cost

Let’s say you pay a coinsurance of 20% on in-network doctor visits.

An in-network doctor has agreed to charge $200 for a simple office visit.
20% of $200 would leave you paying a coinsurance of $40 for that in-network provider.
Your insurance company would pay the remaining 80%, or $160.

What’s your in-network cost for coinsurance?

It’s vital information that can make a big difference when it comes to the cost of medical care, especially if you plan to see out-of-network providers. On average, coinsurance rates health insurance companies pay cover 75 – 90% of healthcare costs, leaving you to pay the rest.¹

The Out-of-network Coinsurance Cost

Now pretend an out-of-network doctor has not agreed to lower their prices for your insurance company.

They charge $300 for the same visit.
For the out-of-network doctor, your insurance company might charge you a higher coinsurance percentage (e.g., 30% rather than 20%).
Plus, you may be responsible for the difference between the in-network and out-of-network bills ($100).
So, you might be stuck with 30% of a $200 charge ($60) plus the $100 difference in doctor’s fees.
That would leave you with a $160 bill.

3. Beware of Out-of-Network Services That Aren’t Covered

Can you just go to an out-of-network provider and expect your health plan to pay for part of your visit? You could, but you could be in for a big surprise when a bill arrives in the mail. In some cases, your insurance company may not pay for care from out-of-network providers at all.

HMOs often work this way. If you need an out-of-network specialist, you may be able to make an appeal to your insurance company and ask them to make an exception in your case, but there’s no guarantee it will be granted.

No Surprise Rules for Out-of-network Providers

If you have to see out-of-network providers, and you’re worried about the cost, you might avoid getting the care you need. Don’t do this. Your health is important. If you get health coverage from the Health Insurance Marketplace or buy a health plan from an insurance company, new rules protect you from things like surprise medical bills and confusing billing practices.²

4. Carefully Compare Out-of-Network Costs

It’s possible to shop around and compare prices for services provided by out-of-network providers. But it might be a waste of your time.

Research shows that only those with health insurance only spend 6.6% of all medical care costs on out-of-network providers.³
Why? Out-of-network costs are rising faster than in-network costs for healthcare. In 4 years, costs for out-of-network services grew by 51%, while costs for in-network services only grew by 14%.⁴

Bottom line: In most cases, in-network services for healthcare will save you money.

5. Plan Ahead When You Can

If you’re trying to navigate the healthcare system and get the most out of your health insurance plan, you need to do your homework. Like many aspects of health insurance, the difference between in-network and out-of-network providers isn’t always simple. Here are some things you can do:

Use in-network providers when you need non-emergency medical care and services.
Compare prices between different out-of-network providers if you need care from one. Even different in-network providers can charge different rates for the same services.
Find out if your healthcare plan posts price information online.
Check your benefits package for information about copays, coinsurance, and out-of-network costs
Call your insurance provider with any questions you have.
Be aware of your choices. You have the right to choose the doctor who will serve your needs best.

Another Way to Manage Out-of-Network Costs: Supplemental Insurance

After doing your homework and taking a closer look at your in-network options, what if you still need care from out-of-network providers? Is there some way to make the out-of-pocket expenses less of a financial burden? The answer may be supplemental health insurance.

HealthMarkets gives you access to supplemental insurance plans that can help you pay your medical costs in case of events like major accidents or serious diagnoses. In these situations, your supplemental plan can help pay your deductibles and other out-of-pocket expenses. But don’t delay. It’s important to purchase supplemental health insurance in advance. These plans may not provide coverage after you have encountered a critical illness or injury.

To find out more about your health insurance options, give us a call at (800) 827-9990. We have licensed insurance agents nationwide ready and waiting to answer your call.