How to Avoid High Out-of-Network Medical Costs



August 11, 2020

The best way to cut costs on medical bills is by staying within your health insurance network. But how do you check if a doctor is in-network before seeing them? And why does that change how much you pay? What does in-network mean anyway?

Let’s start by explaining an ‘insurance network’

Insurance plans cover a specific ‘network’ which is just another way of saying a specific group of doctors (and other healthcare providers, like specialists) and hospitals. You might hear the term ‘provider network’ which also means the same thing. 

Your insurance company has an agreement with this network to provide healthcare services to its plan holders. The reason behind this is all related to the cost of medical care. These providers have an agreement with your insurance company to charge a certain rate. Every doctor’s rate might vary, but if two people with the same insurance contact the same doctor, they will be billed the same amount.

When a doctor or hospital falls within your network, they are classified as “in-network providers.” Does that mean out-of-network doctors are off-limit? Not at all, but it’s important to know what to expect in terms of costs.

In-Network Vs Out-of-Network

A doctor or hospital that falls outside of your insurance network is called ‘out-of-network.’ Sometimes, seeing an out-of-network doctor is unavoidable. A doctor you want—or need— to see might not be covered by your insurance. In that case, it’s important that you make sure you aren’t overpaying. 

Why are out-of-network providers more expensive? 

Well, you don’t get that discounted rate that your insurance company negotiated with the provider. On top of that, your insurance company isn’t chipping in. Instead, you're in charge for the entire bill, as if you didn’t have insurance at all. 

When you first sign up for an insurance plan, it’s important to know what’s in your network. However your health may change over time, and you might need to see doctors or specialists that you didn’t anticipate.

Seeing an out-of-network doctor

If you need to see an out-of-network provider, here’s what you need to do to keep your costs as low as possible:

Ask for approval in advance

If you find yourself seeking a service or treatment not covered by your plan, ask if your insurance company can make an exception. There’s a chance it could be covered if you obtain the necessary approval in advance. 

Call your insurer to confirm what type of plan you have and to ask for the most current listing of the providers in your network. Then, confidently explain why you are unable to see an in-network provider for the situation at hand. Taking this step to contact them ahead of going to an out-of-network provider is important so that they don’t give you a hard time about the associated costs.

The insurance company may or may not cover a certain percentage of out-of-network care. The likelihood of this depends on your type of insurance. In the event that they don’t cover the out-of-network care, they should help you find a provider that meets your needs and is also in-network. 

Get a network gap exception

A network gap exception is when you ask your insurance company to cover an out-of-network service in a similar way to if it were in network. This means that you pay the in-network costs (which is lower) and that part counts toward your in-network deductible. 

Most insurance companies will give you a hard time about making this exception, as it ends up costing them more money. Your insurance company will consider your reasoning behind the network gap extension, and may grant one if it deems that no physicians within the network can provide the essential medical service that you are requesting. 

It’s possible that the out-of-network provider that you are thinking about seeing may be willing to help you communicate with your health insurer and submit this request. But remember, if you go see the provider without securing a network gap extension first, you’ll be responsible for the entire bill.

Call your state’s Consumer Assistance Program

Many states offer help with health insurance questions through Consumer Assistance Programs (CAPs). By phone, mail, or email, they can inform you on how to get or use your insurance effectively. They will take the time to check for options for you, related to your benefits. They may even help you find a new or supplemental health insurance plan.

Look for a new health insurance plan

If you find yourself needing out-of-network providers frequently, then it may be time to get a new insurance plan. You can switch your plan during open enrollment, which is only during a specific time of the year. If your insurance is through your employer, they can inform you of the appropriate dates. The government announces dates for enrollment if you plan to buy an individual policy on the marketplace.

When looking for a new plan, be sure to check thoroughly about the providers in the network. Hopefully you have a good idea of the types of providers you need to see. It’s very important to weigh the pros and cons of all aspects of the plan, from premiums to deductibles to coinsurance, so that you can rest assured that the switch makes sense. 

An Unexpected Out-Of-Network Expense

Have you already been charged an out-of-network expense in a case when you didn’t expect it? It happens more frequently than you would think. 

Surprise medical bills are common. Maybe the network was unclear to the planholder or they did not check for eligible providers ahead of time. It could be that the hospital staffed a specific doctor who is not within the network. Or, there could even be a mistake on the bill.

If you have received a medical bill with unexpected out-of-network charges, you can contact your state legislator, your insurance company, and/or the provider who sent the bill to appeal it.