What Does It Mean for a Provider to Be Out of Network?

What Does It Mean for a Provider to Be Out of Network?
What Does It Mean for a Provider to Be Out of Network?

When was the last time that you gave a speech on a complicated topic? These are the speeches that we get called on to do more and more often. Our audience is facing a difficult decision that they have to make and they are looking to us to explain their options to them. When we find ourselves being asked to give this type of speech, we need to make sure that we take the time to do our homework. We’re going to want to be able to provide a complete overview of the issue to our audience so that they can use what we tell them to make a good decision. Let’s take a look at what we’d have to do if we were talking about selecting out of network providers.

Only 16% of Americans trust their private insurance providers, but that doesn’t mean they plan to ditch those plans any time soon.

After all, what other options are there? Health insurance is something that we need in order to stay healthy and happy.

You may have a health insurance plan that you like or dislike, but a doctor that you love. It could be a doctor you’ve been seeing for years or even a doctor that’s brand new to you.

Either way, knowing what an out of network doctor is can be important when dealing with a health insurance company. Keep reading to learn more.

Out of Network Doctors: What You Need to Know

Some people love going to the doctor’s office while others hate it, but knowing what you need to know before you go is very important!

It helps you make informed choices and know what you are walking into.

In this article, you will get to learn more about why certain doctors are out of network, what this means, and what you can expect from these visits.

What is an Out of Network Doctor?

An out of network doctor is a doctor that does not have a contract with your specific health insurance company. It could be that the contract is not with the doctor, but it could also apply to the entire medical facility.

An in-network doctor is a doctor that has negotiated and decided upon a contract rate with the insurance company, so they are within your network under that insurance plan.

Your health insurance company likely wants you to seek care from the providers within the network because it means they have to spend less money. When you choose to see an out of network doctor, it will end up costing you more money than another option. 

Why Are Some Doctors Out of Network?

There are generally very specific reasons that a medical practice or a doctor will choose not to sign a contract with a health insurance company. 

The biggest reason could be poor reimbursement. This is when the fees that the insurance company approves are not enough to cover the cost of the care that the facility or the doctor provides. 

Knowing which doctors are in your network is very important if you plan to visit a doctor for a procedure or even a check-up.

Even doctors that are specialized, such as a dermatologist, may be covered under some insurance plans. It truly depends on what your health insurance plan is stated to cover.

Doctor visits can become extremely expensive when you have to pay for all of the fees out of pocket and it may even feel like a waste of insurance if you aren’t using it during doctor visits.

How Are These Visits Different?

Let’s use an example to explain this one.

You go to an in-network doctor and the charge after the visit is $300.

Per the agreement that the insurance company has with the doctor, they pay $150 of that amount. You also have a discount applied based on the negotiated rate with the doctor that covers $100. 

This means you only have to pay about $50 for the visit. 

Now let’s say you go to the same type of doctor, but this doctor is out of network. The appointment is the same and the cost is the same, but you are responsible for the whole amount minus the insurance coverage.

There is no discount because there is no agreed-upon contract. This means you have to pay $150 because they are not in the network of doctors. 

As you can see, the biggest difference is that you will have to pay more to see an out of network doctor because that contract giving you the provider discount is not in place. 

Determine Who is In-Network or Out of Network

You generally will need to figure out which doctors are in your network or not because you get to pick your own doctors. The insurance company is not likely going to provide you with a list of doctors and instead may give you the option to search for providers online.

You need to make sure that you ask the right questions before choosing a provider.

Understand that accepting your insurance and being in the network are not the same thing. A doctor can accept an insurance plan, but that doesn’t mean they are in the network.

You may still end up paying more in these types of situations. 

If you want to be certain, you can call the customer service number provided by your insurance company and ask about a specific provider.

They can tell you the network status and whether or not your health insurance company has a contract with them.

Have a Positive Doctor Experience

When you’re searching for a new doctor or deciding whether you want to keep seeing a doctor, you have to consider your insurance.

An out of network doctor is an option for you if you love your doctor and are willing to pay more. An in-network doctor will be more cost-effective with your insurance plan, but may limit your provider options. 

The choice is up to you, but now you have a better understanding of the difference between each option.

Leave a Comment