What is out of network insurance?


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'Out of network' would be a provider that is not part of the 'network' or providers, usually you will have to pay more for that service, as 'in network provider' has a pre-negotiated rate with the company (I'm speaking to health ins.).

--I work in healthcare so to go just a step further. A health plan (insurer) will have a network of doctors that the have agreements with regarding reimbursement for various procedures. An out-of-network provider does not have this agreement in place. For the large amount of policies there is some sort of coverage for out-of-network procedures albeit usually significantly less substantial than in-network. You'll find that most ambulances, anesthesiologists, radiologists, pathologists, emergency room doctors (physicians w/in a hospital). This is because their services are required based on referrals from doctors. Your insurance (particularly with ER, Ambulances, and anethesiologists) will cover these services out of necessity. (I.E. You go to the ER, and they require you get some sort of blood work done. Clearly you did not have time to review your policy to see if the pathologist in the

hospital would accept your insurance.)

It can all be very confusing. I'll conclude by recommending;

- Stay in-network if you can. Most payers (insurance plans) have the network accessible on their websites

- find out your out-of-network benefits from your insurer (almost all plans have them).

- If you get stuck with an out-of-network doctor, find out if you have coverage and if you don't, tell the doctor and they will usually work out some payment arrangement (anywhere from 30-70% off services), they will appreciate you doing this before the service than finding out from the insurer after the service.

- If you have had the service and find out after the fact, call the doctor to arrange payment or look for TPA or cost containment group. They usually can assist in finding some resolution to the problem.

- One loophole in the whole system. If your coverage does not have in-network providers within a certain geographical radius of your home, they are required in many cases to pay for services based on your standard in-network benefits.

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Category: Insurance

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