Healthcare from Out-of-Network Provider and Pay In-Network Rates


There may be times when individuals might need to receive care from an out-of-network doctor or hospital. However, this may require them to pay a lot more than they would if they have stayed in-network. In fact, with plans like HMOs and EPOs, health insurers may not pay anything at all for any out-of-the-network care. Even with the PPO or POS plan that contributes toward out-of-network care, the insured part of the bill will be higher than the insured pay for in-network care. However, there are certain situations when insurers pa for out-of-network care at the same rate that it pays for in-network care, eventually saving a lot of money of the insured. Insured just need to be aware of conditions when insurers will pay for out-of-network care.

Conditions when Insurers Pay In-Network Rates for Out-of-Network Care

State laws regulate health insurance and so each state differs from its neighbor states, so general guidelines are applied to most of the states. In case, if a state law varies, then health plans of that state may follow slightly different rules. Health insurers may consider paying for out-of-network care in the following circumstances:

No Availability of In-network Providers

There might be a possibility that there are no in0network healthcare providers available in the area where the insured is residing. This may mean that the insured got sick while being out of their home town and discover that their health plan’s network doesn’t provide coverage in the city in which the insured is currently present. This might also mean that insured are within their health plan’s regular territory, but their health plan’s network does not include the healthcare specialist which the insured need or the specialist might be far away. In both such circumstances, the insurer is more likely to cover out-of-network care at an in-network rate, if insured inform their insurer in advance and explain about their situation. If it is a non-emergency medical condition, then the insured should follow this approach to avail benefit from their insurer.

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Emergency Situations

There might be an emergency situation for the insured when they immediately visited the nearest emergency room capable of treating their medical condition. Then according to the Affordable Care Act that applies throughout the nation that insurers are required to cover out-of-network emergency care just like in-network care. This means that their deductible and coinsurance cannot be higher than the regular in-network amounts. Insured need to understand that the out-of-network emergency room is not in their insurer contract so they are not obligated to accept their payment as full payment. If the insurers pay less than their actual bill amount, then the emergency room can send insured a balance bill for the difference amount, over and above the deductible and coinsurance amounts paid by the insured. Insurers can escape emergencies like cough, single episode of vomiting, or earache, but they have to cover out-of-network emergency care like strokes, heart-attacks, or life-threatening injuries.

Provider suddenly changes Status

There may be a condition when a healthcare provider may suddenly change their status when the insured is in the middle of a complex treatment. This may be because the insurer was dropped, or the insurer chose to leave the network. This might also happen because of coverage of the insured change. For instance, if an insured has job-based coverage and his employer is not offering a plan that the insured had for years, so he was forced to switch to a new plan. However, in some cases, the current health plan of the insured will allow him to complete the treatment with the out-of-network provider while covering that care at the in-network rate. However, the insured need to immediately discuss this with their insurer after enrolling in a new plan. If the transitional period is approved, then the insured will get the benefit for a temporary period and it won’t give them indefinite in-network coverage for an out-of-network provider.

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Natural Calamity

Natural calamity is something that makes it difficult for the insured to receive in-network healthcare. If the area of the insured faced flood, earthquake, or wildfire that severely impacted the in-network facilities in their area, then the insurer may willingly cover out-of-network care of the insured at in-network rates because the in-network facilities were not able to provide care to the insured.

How Insurers cover Out-of-Network Care at In-Network Rates

Except for emergency care, most of the insurers are not at all enthusiastic about covering out-of-network care at in-network rates. It means that the insurer will pay more for the insured care or they will need to spend on employee’s time and energy that was spent on negotiation for discounted rates for the insured treatment with an out-of-network provider. Though this does not mean that insurer will not pay in-network rates, the insured need to make a convincing argument on why they need the out-of-network care and why receiving care from in-network providers will not work.

Insured have a better chance of receiving out-of-network care at in-network rates is they plan well in advance. If it is non-emergency care, the insured should approach their insurer with the request well before they plan to receive out-of-network care. The process generally takes weeks, so the insured need to be well prepared to support their arguments with facts. Insured need to prove that by using an out-of-network provider might help their insurance company to save money in the long run.

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