Complete Overview on Out-of-Network Provider

healthcare plans

The health insurance sector of the U.S. has divided healthcare providers into in-network providers and out-of-network providers. Out-of-network providers are the healthcare providers who are not contracted with the applicant’s insurance company to render medical care at a negotiated rate. Healthcare plans like HMOs and EPOs do not reimburse out-of-network providers at all. This means that patients would be responsible for the full amount charged by their doctor if their doctor is not in their insurer’s network. Some health plans offer coverage for out-of-network providers, but their patient responsibility would not be the same as the in-network provider.

Key Difference between In-Network and Out-of-Network Providers

An in-network provider is a group of doctors or hospitals that have signed a contract with an insurance carrier to render healthcare services to all its members at agreed-upon discounted rates. For instance, a doctor might charge $150 for an office visit, but he/she might have signed a contract with an insurance carrier to charge $120 as an office visit charge from all its members. Now, if an insured has a $30 copay, then the insurance carrier will pay $90, and the doctor will write off the rest $30 since it is above the network negotiated rate.

Out-of-network providers are healthcare providers who don’t have any agreement or contract with an insurance company. In the majority of cases, healthcare providers sign a contract with few of the insurance companies, so a healthcare provider may be an in-network provider for ABC insurance carrier, but out-of-network provider for XYZ insurance carrier. So, if a healthcare provider charges $150 for an office visit, and he/she is not an in-network provider of XYZ insurance company, then members of this carrier will require to pay full $150 while seeing this doctor. However, some insurance plans may pay a part of the bill, if it includes out-of-network coverage, but individuals will require to pay the full amount if their plans cover only in-network care.

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Reasons behind Doctor Not Included in Insurer’s Network

The common reason for doctors to not join a particular network is, they might not consider the negotiated rates of the insurer adequate to render healthcare services. However, in some cases, even insurance companies prefer to keep their network small so that they can strongly negotiate with the healthcare providers. In such a scenario, doctors might be willing to join the network, but the insurance companies don’t have any network openings available for the medical services that the doctor is providing. Thus, to avoid such situations, many states have implemented “any willing provider” laws that restrict insurance companies from blocking doctors from joining the network, as long as they are willing to meet the insurance companies’ network requirements. States can impose this rule on health plans that are regulated by the state, but for self-insured plans that are regulated by the federal government, this rule doesn’t apply.

How to Check Whether Providers Are In-Network or Out-of-Network?

All the enrollees of a health plan should be aware of the medical providers, who are in-network, and who are out-of-network. Health insurance companies maintain network directories having a list of all the medical providers who are in-network. Healthcare providers who are not on the list are generally out-of-network providers. To know about the out-of-network providers, enrollees can directly make a call to the healthcare provider and inquire whether they are in-network with their specific health plan. Individuals need to understand that a particular insurance company offers different types of plans in their state, and the networks vary from one plan to another. So, if they are calling a doctor’s office to check whether to take their insurance plan or not, they will need to be specific while telling their plan name rather than saying just the carrier name. It is a possibility that the doctor might be in-network for some plans of that carrier but not in all of their plans.

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Reasons to Use Out-of-Network Provider

Though out-of-network care cost more money to enrollees, there may be times when individuals might find it necessary, or they may even be advised to use an out-of-network provider. Find below some of the scenarios in which people might have to avail out0of-network coverage, or it may be automatically granted:


In case of medical emergencies, people are forced to seek the closet medical help available. As per the Affordable Care Act, insurance companies are required to cover emergency care just like in-network care, irrespective of whether emergency care is obtained at an in-network or out-of-network facility. Though, the out-of-network physicians and emergency room can send the balance bill to the patient.

Specialized Care

If an insured experienced a rare ailment, and there is no specialist included in his/her plan, then the person is eligible to receive out-of-network care because it may be crucial for the recovery.

Changing doctors might affect the insured’s health

If an insured is in the middle of treatment for serious or end-of-life issues and their doctor suddenly leaves the network, then it will be in the insured best interest to continue the treatment by going out of network. Insured has the right to appeal for continued in0network coverage if it is required only for a certain period, or for a set number of visits.

Distance Issues

Individuals living in rural areas who don’t have realistic access to any in-network provider in their area, and required continued healthcare, then such individuals can appeal to receive coverage from an out-of-network provider in their area.

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Natural Disasters

Natural disasters like fire, floods, hurricanes, and tornadoes may destroy medical facilities and force people to move to other areas in which they might receive healthcare. Thus, these patients are eligible for in-network rates as part of a declaration of emergency by the state or federal government.

Regulations for Network Adequacy

For health plans sold in the health insurance exchanges, the ACA has implemented rules that these plans are required to maintain adequate networks and have up-to-date network directories readily available online. However, in 2017, the Trump Administration started deferring to the states for network adequacy determinations, thereby weakening the implementation of network adequacy standards. Networks have narrowed from the time since ACA-complaint plans first became available so individuals buying coverage in the individual market today generally have smaller networks than in the past. Thus, it becomes essential for the enrollees to double-check the network of any plan, which they are considering to buy and if they have a doctor to whom they want to continue to see.

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