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Out-of-Network Providers & How to Handle Them

Out-of-Network Providers & How to Handle Them

When choosing an insurance provider, understanding which medical providers are both in and out-of-network is crucial. This will determine which providers will accept your coverage, and which providers will not. Read on to learn how you can make the most of your network coverage and remain financially prepared for all of your medical charges. 


Comparing In-Network and Out-of-Network

In-network simply refers to those providers who are within your insurance network. An insurance network is defined as a group of providers and physicians who have contracted with the insurance company and agree to certain network rates, requirements, and discounts. When a provider is considered in-network, the insurance company will generally cover a greater percentage of expenses depending on your plan. Most people will choose to utilize an in-network provider to ease the financial burden of medical care. 

In contrast, out-of-network refers to providers who are not within your health insurer's network and maintain no contact with the insurance provider. Generally, your insurance will cover less of the overall costs, and these physicians and providers may not accept aspects of your insurance. 


When Should You Use Out-of-Network?

Generally speaking, it is always best to consider an in-network provider as opposed to one that is out-of-network. That said there are times when you may not have much of a choice. 

  • If you are taken to a hospital by ambulance, then you will often have no choice in which hospital you are taken to. 

  • There may be times when an in-network provider cannot be found within a reasonable distance for a specific specialty or treatment, forcing you to look out-of-network.

  • You may be specifically referred to a specialist who happens to be out-of-network. 

  • You change your job or coverage plan and your preferred provider is no longer in-network.

As you can see there are many different reasons one might choose to utilize an out-of-network provider. That said, it will generally make more sense financially to use a provider who is in-network whenever possible.


How to Make the Most of Out-of-Network

The first step to handling out-of-network costs is to educate yourself on the details of your health plan. Take the time to fully understand what costs are being covered and what percentage of those costs are covered for both in and out-of-network costs. 

Once you understand your plan and the details regarding coverage, take a look at which providers are considered in-network and which ones are not. Just knowing this information can help you to prepare for what out-of-pocket costs you may incur should you need to use a provider who is out-of-network. 

If you must utilize an out-of-network provider, then there are some ways that you can handle the costs to reduce their burden. 

  • If you notice that a provider is out-of-network, be sure the same services are not available through a different provider who is in-network.

  • Once you know that you will be using a provider who is out-of-network, reach out to the hospital or provider to inquire about any assistance programs that might be available

  • Consider different drug options including local pharmacies or large retailers who may have discounts available. GoodRx is a great example of this. 

  • Always ask questions. Many times physicians will recommend different or additional tests, such as blood work. These may not be covered by your insurance, so it is always a good idea to check with the physician or provider before agreeing to any extra testing.

  • Utilize a health cost calculator. This is a tool that can be used to determine how much a medical procedure or treatment should cost. Fair Health Consumer has a calculator for this reason that can be very helpful when analyzing whether or not you’re getting a fair price.  

  • Lastly, check with your insurance provider before paying for out-of-network costs. There is a good chance that they will be willing to pay some of the out-of-network expenses under certain circumstances. These can include emergency situations, lack of available in-network providers, natural disasters, or changes in your typical provider's status. 

Keep in mind that all insurance providers are different and so it is always a good idea to reach out and discuss any questions or concerns you may have as soon as you are aware of potential costs. The sooner you reach out, the better chance you have of planning accordingly for the financial repercussions. 

There are also laws and regulations that differ by state. Always do your research to first determine what regulations are in place, and then work with your provider to determine a course of action that is suitable for your situation. 


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