In-Network vs. Out-of-Network: An Overview
Some people pay a higher price by seeing an out-of-network clinician. It is your right to ask how much procedures will cost.
Most patients are loosely familiar with the terms in-network and out-of-network, but some individuals may be unsure how and when they apply. There are several nuances to these terms, so to take care of yourself and your finances, it’s best to have a comprehensive idea of what these terms are.
In-network clinicians are those health care providers that your health insurance has negotiated fees and agreements with. Because of this agreement, the provider is likely to get more business from patients from this insurer, and the patient has a group of clinicians that they can use for different health protocols for a lower price.
Who does the distinction apply to?
This can be tricky. Most people end up paying a higher price by seeing a clinician they thought was in-network, but was out-of-network for the following reasons:
Referrals. If your regular clinician cannot figure out the best method to treat a wound, illness or health issue, they will usually refer you to a different specialist. However, your clinician may not check to see whether or not this specialist is within your network, so it’s up to you to ask about this before you make an appointment. A customer service specialist at your health insurance company will also be able to help you figure this out.
Different types of clinicians within an in-network hospital. This is probably the most nuanced in-network/out-of-network distinction. Although a hospital that you visit may be in your health insurance network, the different types of clinicians – cardiologist, phlebotomists and others – may not be covered. Before anyone sends you to a particular office or hospital branch, do not be afraid to ask if the specialist is in your network. It’s your money and your health, and you have a right to be part of the decision. You can also contact the specialists that you will see to ask them how much the procedure will cost you.
Out-of-network clinicians and services cost more than those services that are provided in network. If you have an HMO or EPO plan, most out-of-network providers have to pay the full cost of any clinician visit. If you have a PPO or POS plan, out-of-network options usually come with a higher copay than what you would pay for similar in-network clinicians, as well as a higher percentage of co-insurance.
When should they be used?
Contrary to popular belief, an out-of-network provider may sometimes be your best bet for the care you need. If you need or want a procedure that is not covered by your current plan or health insurance carrier, you may have to go out of network. This option is often used in situations where life is at stake, when the costs of the surgery or procedure outweigh the costs of living with the disease or condition.