Understanding the Process: How to Navigate Insurance for Out-of-network Services

Understanding the Process: How to Navigate Insurance for Out-of-network Services

Insurance is a giant rainy day fund paid into by many (called policyholders) to mitigate losses they might incur. The insurer agrees to pay for claims that meet certain conditions.

Patients should use providers that are in their health plan network. But that’s only sometimes feasible or possible. If a doctor is not in your network, you can negotiate for a contract at an in-network rate. This negotiation process, often referred to as payer contracting, is crucial when seeking affordable healthcare outside of your network. Healthcare providers — doctors, other healthcare providers, pharmacies, and facilities — that have a contract with your health insurance provider are called “in-network.” When you see an in-network provider, your costs are typically lower. In-network providers have negotiated with the insurance company to accept a pre-determined rate as payment in full for services rendered. This is why knowing if a healthcare provider is in or out of the network is essential before you receive any benefits

Healthcare providers without a contract with your health insurance provider are considered out-of-network. When you visit an out-of-network provider, your costs are generally higher – unless you have a situation where changing providers would jeopardize your health. In this case, you may be able to appeal to your insurer to provide continued in-network coverage for a specified period.

Out-of-network benefits are limited to a maximum of what your plan considers to be the “reasonable and customary” amount the service should cost. The actual amount paid varies by health insurance company. Your health plan should explain how out-of-network benefit limits are set for your specific project.

Now, how to get insurance to cover out of network services? You should know that, even if you’ve agreed to go out-of-network for certain services (such as in the case of an emergency), the healthcare provider can still be balance billed for the remaining portion of your charges after your health insurance pays their part of the bill. It would help if you asked the doctor for a statement of the fees they will charge and your share before scheduling the procedure.

Know Your Plan

You’ll get the best results from staying in your plan’s network, but sometimes that’s impossible. It’s essential to understand how your insurance company works in those cases.

Start by reviewing your “summary of benefits and coverage” (SBC), a snapshot that should have been provided to you by your insurer or employer when you signed up for the plan. This gives a good overview of your plan’s costs, coverages, and exceptions.

Some plans, such as HMOs, require you to stay in-network and will only pay for services provided by an in-network provider. Others, such as PPOs and point of service (POS) plans, are more flexible. These programs may allow you to visit out-of-network providers but may charge you a higher copayment. You should also review your provider directory, which should list doctors and healthcare facilities participating in your insurance plan’s network. You may have to request a specific form of coverage from your insurance company for out-of-network expenses, which you should find in your plan documents or online marketplace.

Ask Questions

To ask practical questions, it helps to have a clear idea of what you’re trying to discover. Do preliminary research to develop a question that will help you get your desired answer without burdening the respondent.

The best questions are open-ended, leaving room for opinion and eliciting information rather than just answers. They can be framed using the eight wh-questions: what, when, where, who, which, why, and how. Closed questions that can be answered with a simple yes or no tend to prompt factual and short responses.

Asking good questions is a skill that can be practiced and improved upon. Here are some steps and expert tips to help you hone your question-asking skills.

Get a Quote

Health insurers create networks of doctors and facilities with which they’ve negotiated rates. Doctors and facilities in the network will be listed in the insurer’s online directory, making it easy to determine whether they’re in-network or out-of-network. When you see an in-network provider, the cost of your appointment will generally be lower because the provider has agreed to accept the insurance company’s negotiated rate as payment in full.

Out-of-network providers do not have a contract with your health insurer, so they can charge whatever they want. They may even balance bill you, meaning they’ll send you an invoice for the remaining amount after the insurance company has paid its share.

Some recommend contacting the out-of-network provider directly and trying to negotiate a price. They say, “Be polite and explain that a particular insurance plan ensures that you would like to use their services and would appreciate their consideration for a discounted rate.” Be sure to get any agreements in writing. Also, keep notes of each phone conversation.

Follow Through

When a health insurance carrier denies an insured’s request for out-of-network care, it must provide the reason for that denial in writing. The information should be available on the insurer’s website or within the plan documents.

Doctors and health care providers that are part of a plan’s network have agreed to contract directly with the health insurance carrier to help control costs and keep members’ premiums affordable. Doctors and health care providers not part of a plan’s network are considered out-of-network and allowed to charge whatever they want for services.

When a surprise bill occurs, the non-participating provider is billing the health insurance company for more than the amount that the health insurance company has already paid. If the health insurance company has a standard form for certifying surprise bills, that form should be completed. If the health insurance company doesn’t have a standard format for surprise bills, the law provides protections.

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