IN AND OUT-OF-NETWORK BENEFITS

In-Network and Out-of-Network

Everyone uses different criteria to select a new doctor. But, is the insurance company’s network part of your list? You may wonder, “How does it impact me and why should I even care?” Paying attention to whether or not your healthcare providers are in your insurance company’s network is a good idea and an excellent way to save, or at the very least avoid paying more than what’s necessary. While in-network and out-of-network terminology sounds confusing, this guide will help you to understand the impact of your insurance company’s network.

What is a Network?

Your insurer has identified a group of providers who are “in-network” and has contracted with these providers on your behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that you receive this negotiated or discounted rate for their services, and your insurance generally picks up a larger portion of the bill than with an out-of-network provider.

Understanding How In-Network vs. Out-of-Network May Affect May Affect Your Pocketbook

An example: A visit to an in-network physician may charge $100 for an office visit. Your insurance company has contracted with them to discount this visit to $60. If your insurance company covers 80% of the cost, the patient responsibility would be $12. Compare with an out-of-network physician that also charges $100. Without the negotiated rate from you insurance company, your cost will remain $100. For out-of-network providers and care, your insurance may only cover 50%, making your patient responsibility $50.

I Went to an In-Network Provider: Why Weren’t All of my Services Covered?

Remember, just because a provider is in-network, it does NOT mean all the healthcare services and treatments you receive will be covered. Using an in-network provider simply means that when you receive services from the provider, your insurance will get you the negotiated rate for the services. They will then provide you with the coverage outlined in your policy. Insurance plans can be confusing, so make sure to check your insurance policy eligibility and benefits..

Are They In or Are They Out? How do I Find Out Who’s In-Network?

Doctors frequently move in- and out-of-network. The day the network book is printed or the website is updated, it’s out of date. Doctors have been added. Doctors gave failed to renew their contract or opted out of a network. Basically, the information is out of date, and until you check with the provider, you really don’t know. Check with your provider when you schedule a visit or before you receive services (when you check in for the appointment). They will need to know your insurance, possibly your group number as well as your “network." All of this information should be on your insurance card.

The Out-of-Network Service Provided through an In-Network Provider

It’s possible to go to an in-network provider or facility and receive services from a provider who is out-of-network.