If you’re getting care from an out-of-network provider, you’ll likely have to pay a higher copayment or deductible.

You can reduce your financial risk and get better quality care by staying in-network. But you must choose your doctors and facilities carefully – or you could face unexpected bills.

What is an Out-of-Network Provider?

If you are wondering what is out of network insurance billing, read on. An out-of-network provider is a medical professional that does not belong to your health insurance company’s network of doctors and hospitals. This means you will pay a higher cost-sharing (deductible or copay) when you visit them for treatment.

Most health insurance plans offer a list of providers in their network. These doctors and hospitals contract with insurance companies to provide care at a negotiated price.

However, when you need to get care from an out-of-network provider, things can become tricky. 

In general, you should only get medical services from doctors and facilities that are part of your insurance company’s network. This will save you money and avoid surprise medical bills, but check the provider’s prices before visiting them to ensure that you get the best deal possible.

Why Are Out-of-Network Providers More Expensive?

Health insurance plans often use provider networks to ensure their members get the most affordable care. This network comprises doctors, hospitals and other healthcare providers who have negotiated discounted rates with insurers.

In addition to lowering out-of-pocket costs, provider networks also help to protect patients from high medical bills. Insurers screen and monitor healthcare providers in their networks to ensure that they are providing safe and effective care. They may check their licensing status, that recognized healthcare accrediting organizations accredit them and that they measure up to quality standards.

Moreover, health plans often have a deductible (also known as your “share of cost”) that you must pay for services before your plan covers them. You can learn more about your deductible by reviewing your health insurance policy or speaking to your doctor or insurance agent.

Many medical procedures performed by in-network physicians are significantly cheaper than those achieved by out-of-network providers. For example, Medicare pays an average of $147 for a 40-minute office visit. In contrast, the same visit would cost over $10,459 from an out-of-network provider, according to a study released last year by America’s Health Insurance Plans.

While some out-of-network providers charge higher prices than their in-network counterparts, it is more likely that the costs will increase over time. For instance, research has found that the average allowed spending per out-of-network service rose 23 percent from 2014 to 2017, while the average billed charge rose even faster at 51 percent.

What Can I Do to Make Out-of-Network Care More Affordable?

Choosing an insurance policy with some out-of-network coverage can help you avoid surprise medical bills. It also gives you more access to specialized care. However, it may not be worth the extra money you’ll pay for out-of-network coverage if you don’t have a health condition requiring special care or your insurer doesn’t have doctors in your area.

A significant issue is that out-of-network hospitals often demand more money from insurers to keep them in their network, which can drive up prices. These costs are typically passed on to consumers through higher deductibles and coinsurance rates.

A few bipartisan legislation have been passed to protect consumers from these surprise bills. The No Surprises Act, which goes into effect in 2022, will make it illegal for health insurance companies to surprise consumers with out-of-network bills.

Another way to mitigate the cost of out-of-network care is to request a network gap exception from your insurance provider before you receive any services. This will allow you to receive treatment at lower in-network prices, and your portion of the bill will count toward your in-network deductible.

Out-of-network limits could significantly impact affordability and access more than bans on surprise billing. These limits would likely reduce in-network negotiated rates, encourage providers to remain in-network and limit overall spending. Researchers suggest that these limits are essential to level the bargaining power of hospital systems and health insurers, thereby promoting greater consumer access and lower costs.

How Can I Make Out-of-Network Care More Convenient?

Whether you have a health plan that requires you to use in-network providers or want to be able to use whichever doctor you choose without worrying about deductibles or copays, there are some ways to make out-of-network care more convenient. The best way to do this is to keep an open communication line with your out-of-network provider and your insurance company.

In addition to educating yourself about your health insurance plan, keeping an eye on prices when you’re getting out-of-network care can be helpful. Most programs have a website that offers price information, and you should be able to call your insurer with any questions.

Your doctor can also help you navigate your out-of-network costs and benefits. This can include finding out if your plan has a high deductible, how much your copay and deductible will be based on the type of care you receive, and how to request preapprovals for certain services.

Another essential part of making out-of-network care more convenient is requesting medical records. This can help your in-network providers understand what’s going on with you and can even lead to faster treatment if you have a history of problems or are receiving ongoing therapy.

Lastly, if you need to go out-of-network for an emergency or specialty care that your insurer doesn’t cover, you should be prepared to negotiate with the out-of-network provider to get a better rate on the service. This can save you a lot of money in the long run.