What Is the Difference Between In-Network and Out-of-Network Providers?

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Out-of-Network Providers
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When you call around for an appointment with a specialist or get a referral from your primary care physician, it is important to know if the doctors are in-network. The difference between in-network and out-of-network providers can be confusing and affect your ability to access care. Here’s what you need to know about each type of provider.

How Do Different Types of Plans Use Provider Networks?

In 2020, 91.4% of Americans were covered by private or government health insurance. However, not all these insurances are the same. Depending on your health insurance plan, your coverage may be limited to care from a network provider. You might have to pay more if you get care from a provider outside the network or receive prior approval. Some types of plans include:

Exclusive Provider Organization

An Exclusive Provider Organization (EPO) is a type of health insurance plan that limits your choices to certain providers. It’s also referred to as a closed panel plan. In an EPO, you can only see doctors in the network offered by your insurer.

If you want to see a doctor outside of the network, you must cover all costs yourself. The only exception is if you need emergency care and there’s no other option for treatment within a reasonable distance from where you live. The benefit of an EPO is that it can cost less than other types of health plans.

Health Maintenance Organization

A Health Maintenance Organization (HMO) is a health insurance plan requiring you to get care from a doctor who works for or contracts with the HMO. You aren’t covered for out-of-network care except in an emergency. You may have to live or work in the HMO’s service area to be eligible for coverage.

Point of Service

Point of Service (POS) plans offer lower co-pays if you use doctors and hospitals that are a part of the plan’s network. Using the services of someone outside the network results in higher payments. However, you might need a referral from your primary care doctor if you want to consult a specialist.

Preferred Provider Organization (PPO)

Preferred Provider Organization (PPO) plans use a network of healthcare providers, usually larger than other plans. The PPO plan will pay for services rendered by these doctors at a discounted rate, and you’ll spend less out-of-pocket than if you went to another provider. This plan allows you to consult with doctors and hospitals outside of the network providers without incurring any extra cost.

What Is an In-Network Provider?

An in-network provider is a doctor, hospital, or another healthcare facility that has agreed to accept the negotiated rate set by your insurance company. Those providers are often referred to as “preferred” or “in-network” providers.

In some instances, you may want to choose an out-of-network provider because they offer services not covered by your plan through their network. The costs of these services may be higher than what your plan covers if you use in-network providers only.

What Is an Out-Of-Network Provider?

An out-of-network provider is a doctor or other healthcare professional not part of your health insurance plan. They may be more expensive than in-network providers, and you may have to pay the total cost of an out-of-network provider’s bill.

You should check with your insurance company if you’re unsure whether a provider is in-network. The Affordable Care Act (ACA) requires that health plans sold through the marketplace give information to all the enrollees as well as prospective enrollees about the availability of both in- and out-of-network providers.

What Happens if You Go to an Out-Of-Network Provider?

If you go to an out-of-network provider, your insurance company may not cover all the charges. You may have to pay more out-of-pocket costs than if you had gone to a doctor in their network. You would also have to pay the total cost of services.

The reimbursement of your expenses may vary. The out-of-network provider may bill you for the difference between what they charged and what your insurance company pays. This can happen when a doctor or hospital is not in your network, but one of their doctors or hospitals is.

For example, you may only get 80% of the cost covered. Your insurance company may send you a letter with information about how much they will pay and how much you have to pay.

To ensure that you can get reimbursed for the services provided by an out-of-network provider, check with your insurance company before making an appointment with a new doctor. The No Surprises Act, which goes into effect in 2022, requires all private health plans to maintain accurate provider directories and also requires providers to update the directories regularly.

If you’re denied a claim by your health insurer, you may appeal the decision and have it reviewed by a third party.

How Do You Find a Provider Who Accepts Your Health Insurance?

You can find a provider who accepts your health insurance by asking your doctor, checking the list of in-network providers on your insurance card, or calling the customer service number for your plan. Research conducted across health networks in 2020 concluded that employer-sponsored health plans tend to offer broader networks of doctors and hospitals than the health plans available through the marketplace or managed Medicaid plans.

To find out if the provider you want to see is in-network:

  • Ask your doctor. It’s best to start here because familiarizing yourself with his or her services will help you know what kind of care they provide and whether your plan covers it.
  • Ask your insurance company directly or check their website for an up-to-date list of in-network providers offering similar services to those provided by the provider you’d like to use. Then contact them directly using their website’s contact form or phone number listed there or simply call their customer service line and ask.
  • Check with any other administrators who might have more knowledge about this topic than others. For example, you can consult with human resources staff at workplaces.

Conclusion

Health insurance companies pay a certain amount for in-network medical care. If you go to an out-of-network provider, you may have to pay more for services. However, there are some exceptions to this rule. 

For example, if your plan has a higher deductible than usual or the out-of-network provider charges less than what your insurance network will pay. The best way to avoid surprises is by knowing which providers are covered under your plan before making any appointments.

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