Orlando Harmon
Going out of your insurance provider's network to get care can have several implications, including increased financial risk and quality issues with the healthcare received. When you go out of network, you lose the benefit of negotiated discounts, and your share of the cost (deductible, copay, or coinsurance) is typically higher. Some plans, such as HMOs or EPOs, may not cover out-of-network care at all unless it's an emergency. Federal and state protections may prevent balance billing, which is when you are charged the difference between what insurance covers and the provider's actual bill. It's important to understand your plan's benefits and limitations, as well as any consumer protections that may apply, to make informed healthcare decisions and avoid unexpected costs.
| Characteristics | Values |
|---|---|
| Plans required to cover care received from an out-of-network provider | Not required, but may be covered with higher cost-sharing |
| Protection from "balance billing" | Federal and state protections available in certain situations |
| Cost-sharing | Higher when out-of-network |
| Deductible | Insurer may set a different deductible |
| Out-of-pocket limit | Costs may not count towards annual out-of-pocket limit |
| Discounts | No negotiated discounts, only self-negotiated discounts |
| Coverage | May not be covered by HMO or EPO plans unless it's an emergency |
| Consumer protections | Generally not available when choosing to go out-of-network |
| Emergency care | Under the ACA, insurers must count emergency care as in-network |
| Non-emergency care | "Surprise" balance billing prohibited under the No Surprises Act if received unknowingly at an in-network facility |
| Ambulance services | Generally not covered by the No Surprises Act, unless state law differs |
| Vision and dental insurance | Generally not protected by the No Surprises Act |
| Post-stabilization services | Likely to pay more for out-of-network care |
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What You'll Learn
You may have to pay more
When you go out of network with insurance, you may have to pay more. Out-of-network providers do not have to limit their charges to what your insurer considers reasonable, and you may end up paying balance billing charges, which are the difference between what your insurance covers and the provider's actual bill. These charges can be significantly higher than in-network rates, and your insurance plan may not cover any of these additional costs.
The amount you pay out of pocket for out-of-network services depends on the type of health insurance you have. If you have an HMO or EPO plan, your health plan may not cover out-of-network care at all unless it is an emergency. Even if your plan does cover out-of-network services, your insurer may set a different deductible and may not count these costs towards your annual out-of-pocket limit. As a result, you could end up paying much more for the same service compared to using an in-network provider.
In some cases, you may unintentionally receive care from an out-of-network provider while at an in-network facility. For example, you may seek treatment from an ancillary provider such as a radiologist or anesthesiologist who is not contracted with your insurance company. In these situations, the No Surprises Act prohibits surprise balance billing, and you are protected from unexpected out-of-network charges. However, this protection does not apply to all settings, such as a doctor's office that is not a hospital outpatient department, or to all services, such as ground ambulance services.
To avoid unexpected costs, it is important to educate yourself about your insurance plan's benefits and limitations. Review your plan to understand what is covered and what your financial responsibility would be if you choose to go out of network. Ask questions and keep thorough notes to help keep track of your healthcare bills. Additionally, consider whether the same service is available within your network, as switching to an in-network provider may be a cost-saving option.
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You may not be protected from balance billing
When you go out of your insurance network, you are at risk of balance billing. Balance billing occurs when an out-of-network provider charges you for the difference between what your insurance covers and the provider's full charge for their services. This can happen when you actively choose an out-of-network provider, or when you have no choice in the matter—for example, in an emergency or when receiving care at an in-network facility from an out-of-network provider.
While federal and state protections exist to prevent balance billing in certain situations, you may not always be protected. Here are some scenarios where you may still be billed for the difference between your insurance coverage and the provider's charge:
- Choosing an out-of-network provider: If you choose to go outside your insurance network, you may be balance billed. This can happen even if you have a valid reason for doing so, such as the out-of-network provider having better reviews or a more convenient location. In these cases, it is important to understand how going out of network will affect your coverage and the potential costs involved.
- Receiving post-stabilization care out of network: After receiving emergency care and your condition has stabilized, you may require additional care to maintain your health. If you choose to receive this post-stabilization care from an out-of-network provider, you may be balance billed.
- Using ground ambulance services: Ground ambulance services are generally not covered by the billing protections in the No Surprises Act. They are often allowed to charge out-of-network rates, which can result in balance billing.
- Vision-only and dental-only insurance plans: The No Surprises Act's billing protections do not typically apply to vision-only and dental-only insurance plans. However, if vision or dental benefits are included in your health plan, you may be protected from balance billing in certain circumstances.
- Self-insured health plans: While the No Surprises Act aims to protect consumers from surprise balance billing, it does not apply to self-insured health plans, which account for a significant portion of employer-sponsored coverage.
To reduce your chances of receiving a surprise balance bill, it is important to understand your health plan, including which providers are in-network, and to check with your state's Department of Insurance (DOI) for any applicable protections.
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You may not have access to discounted rates
When you go out-of-network, you lose access to the discounted rates that your insurance company has negotiated with in-network providers. These discounted rates are typically only available to in-network providers because your insurance company has agreed to include them in their network. When you go out-of-network, you are responsible for negotiating your own rates, which can be challenging if you don't have experience in this area. As a result, you may end up paying much higher prices for your medical care.
The difference in cost can be significant, as out-of-network providers can charge whatever they deem appropriate, without considering what your insurer believes to be a reasonable price. This can result in "balance billing", where you are charged the difference between what your insurance covers and the provider's actual bill. While there are some federal and state protections in place to prevent balance billing in certain situations, such as emergencies or post-emergency stabilization care, it is not always covered.
It's important to understand that your insurance plan may not cover any out-of-network costs. Even when it does, the coverage may be much lower than for in-network services, resulting in higher out-of-pocket expenses for you. The specific details of your plan will determine how much you will be charged for out-of-network care. Therefore, it is crucial to review your plan and understand what is covered before seeking medical treatment outside of your network.
To make informed decisions, it is essential to be well-informed about your insurance plan's benefits and limitations. Knowing what is covered and what is considered out-of-network can help you avoid unexpected costs. Additionally, staying within your network whenever possible can help you maximize the benefits of your insurance plan and minimize your out-of-pocket expenses. If you are considering switching plans, be sure to verify that your preferred providers are included in the new network to ensure your healthcare needs are met.
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You may have to pay the full amount
When you go out of network with insurance, you may have to pay the full amount for the services you receive. This is because your insurance company has not negotiated discounted rates with out-of-network providers, so you are not protected by your health plan's discounts. As a result, you may be charged significantly more for the same service compared to an in-network provider.
The amount you will have to pay depends on the type of insurance you have. If you have an HMO or EPO plan, your health plan may not cover out-of-network care at all unless it is an emergency. Even if your plan does cover out-of-network services, you will likely have a higher deductible, copay, or coinsurance to pay.
In some cases, you may unintentionally receive care from an out-of-network provider, such as when you seek treatment at an in-network facility but are treated by an ancillary provider (like a radiologist or anesthesiologist) who is not contracted with your insurance company. This is known as "surprise" balance billing and is prohibited under the No Surprises Act. However, this protection may not apply in all settings, such as at a doctor's office that is not a hospital outpatient department.
To avoid unexpected costs, it is important to educate yourself about your insurance plan's benefits and limitations. Review your plan to understand what is covered and what your financial responsibility would be if you choose to go out of network. Ask questions and keep thorough notes to help keep track of your healthcare bills.
If you do receive a surprise medical bill from an out-of-network provider, you can take steps to dispute the charges. You can request an internal appeal and external review, contact your state insurance department for information on the appeals process, or submit a complaint to the No Surprises Help Desk.
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You may be able to appeal
If your insurance claim has been rejected because the provider was outside of your coverage network, you can appeal the decision. You do not have to accept the rejection. An experienced insurance claim denial attorney can help you fight back against a wrongful denial and ensure the insurance company is held accountable for its mistake.
There are two ways to appeal a health plan decision: an internal appeal and an external review. If your claim is denied or your health insurance coverage is cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process. If your request is approved, ask for a case manager to handle your out-of-network claims.
If your request is denied, federal or state law may require your insurer to allow you to start an "external" appeal. This means you appeal to an independent, outside group, and the insurance company no longer has the final say over whether to pay a claim.
If you received a surprise medical bill after choosing an out-of-network provider because you felt it was necessary, you can ask for an internal appeal and external review. Contact your state insurance department for more information on the appeals process and to see if there are programs to help you with your appeal.
To avoid the need for an appeal, it is best to work out the details with the insurer in advance. Request that your insurer covers you at the in-network rate before you go out of network. If your medical need is urgent, ask for an expedited appeals process.
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Frequently asked questions
Going out of network with insurance refers to receiving care from a healthcare provider or facility that is not part of your insurance company's provider network.
There are financial risks associated with going out of network. Out-of-network providers do not have negotiated rates with your insurance company, so you may end up paying higher costs for their services. Your insurance plan may not cover out-of-network care at all, leaving you fully responsible for the charges.
Yes, there are some federal and state protections in place. The No Surprises Act, for example, protects patients from "surprise" balance billing if they unknowingly receive care from an out-of-network provider at an in-network facility. Federal law also protects you from out-of-network charges for emergency services in hospitals and certain other settings.
If you receive a surprise out-of-network bill, you can contact your state insurance department to learn about the appeals process and file a complaint. You can also reach out to the No Surprises Help Desk for assistance.
To avoid unexpected charges, it is important to understand your insurance plan's benefits and limitations. Educate yourself about what providers and services are covered, and consider reaching out to your insurance provider or HR manager if you have questions.
