An-out-of-network care provider is one who hasn't agreed to participate with your insurer or accept the negotiated rates your insurer pays for a particular medical service. Depending on your insurance plan, you may have no coverage for out-of-network care, or you may have to pay higher co-insurance costs and meet a higher out-of-network deductible if you see a doctor who doesn't participate with your insurer. You may also end up paying the difference between what the doctor charges for a specific procedure and what your health insurer is willing to pay for that care.
All of this can add up to big bucks. If you need to see a physician who doesn't participate with your insurer, it's important to plan for handling this so you don't end up with healthcare bills that are too hard to cover. If you're not sure what to do about an out-of-network doctor, here are some of the steps you may want to take to help keep your costs down.
Ask for a network gap exception
When you request a network gap exception, you ask your health insurer to cover out-of-network care as though it were in network. This would mean that you pay for care at the lower in-network costs and that your portion of the care you pay for counts toward your in-network deductible.
Health insurers won't grant network gap exceptions for no reason and, in fact, most don't want to grant these exceptions because they end up incurring extra costs. But if you cannot get the care you need because your insurer's network is too narrow and doesn't cover any physician who offers essential medical services, your insurer may grant one. Typically, insurers will do this only if you are requesting a type of care your insurance covers that is medically necessary and that isn't offered by an in-network provider within a reasonable distance.
If you plan to request an exception, you must do so before you get care -- otherwise your claim will simply be processed at the higher out-of-network rates. Your out-of-network provider may be willing to help you deal with the insurance company to make this request, or you may be on your own to complete the right paperwork or figure out the right people to get on the phone.
If you've researched your options to find in-network care and can't find any, get out your insurance policy or give your insurer's customer service line a call to find out about the process of requesting a network gap exception.
Find out up front how much you'll be billed for services
If your insurer won't grant you a network gap exception and you still want to visit an out-of-network doctor, you need to know up front exactly what extra costs you're looking at.
Check your insurance policy first because you'll probably be subject to higher co-insurance and co-pay costs, and you'll also likely have a higher deductible for the out-of-network care -- if it's even covered at all.
For example, you may have a $2,000 in-network deductible but a $5,000 out-of-network deductible. This means you would have to pay $3,000 more in costs with your out-of-network provider before care is covered. Or your insurer may pay only 50% of the bills when you see an out-of-network provider, whereas you may have only 20% co-insurance costs for in-network providers.
It's not just the deductible and added co-pays or co-insurance you have to worry about, either. The doctor who is out of your network doesn't have to agree to accept the rates your insurer provides. For example, your insurer may have agreed to pay $150 for a particular lab test -- but the out-of-network doctor may charge $300 for the test. If so, you could be responsible for paying the added fees above what your insurance covers. And that extra $150 that your insurer won't pay won't count toward your deductible, either.
This is a huge problem that can make out-of-network care much more expensive than most people even anticipate, so be sure to do the research to fully understand all your out-of-pocket costs.
Talk to your doctor about a discount or a payment plan
If you're going to see an out-of-network doctor and incur big costs, find out what options you have for paying them.
Some doctors may be willing to offer a discount if you pay cash instead of going through insurance -- and it can be worth it to do this if your insurer provides limited or no coverage for out-of-network care anyway. Other doctors allow you to pay for your care in installments.
Look into switching policies during open enrollment
Finally, if you find yourself repeatedly needing to see an out-of-network doctor, this may suggest your insurance plan isn't working for you. Unfortunately, you can switch plans only at certain times of the year called open enrollment. Your employer sets open enrollment dates if you get insurance through your company; the government announces the dates if you buy an individual policy on an Obamacare exchange.
During the next open-enrollment period, shop around for plans available to you. Check the provider network offered by different insurers and see if you can find one with your chosen caregivers in its network. Even if you have to pay higher premiums, it may be worth it to get the care you want from the doctor you prefer.
Don't get sick from a doctor's bill
Now you know your options when the doctor you need is out of network. This is a difficult position to be in, but being proactive could help you to ensure you get the care you need without blowing your budget.