You might need to use an out-of-network provider for several reasons. Maybe you experienced a medical emergency and had to be treated at the nearest hospital. Or perhaps you needed to see a specialist, but the closest one in your network was hundreds of miles away.
Whatever the reason, health care costs associated with a provider outside of your insurance network can be expensive. But you may not need to foot the whole bill.
Below, you’ll find out how to deal with out-of-network insurance charges, including how to tell what your insurance policy does and doesn’t cover, how to negotiate out-of-network charges, and how to avoid billing surprises. Make sure you’re covered when getting medical treatment without paying extra money out-of-pocket.
What Is an Out-of-Network Charge?
Most insurance plans have a provider network, which is a group of doctors, hospitals, and other care providers under contract to provide medical care to its members at a discounted rate. Insurance companies offer different plan types that have different networks.
If you seek care from a provider outside of plan’s network, your insurance may not cover the cost (or won’t cover as much of it) and you’ll incur out-of-network charges for the services you received.
How To Negotiate Out-of-Network Charges
Ideally, you should avoid out-of-network services to prevent large medical bills. That means checking to make sure that any medical provider you’re going to use is in your health plan’s network. “That’s something you’ll want to do any time you’re making an appointment, as provider networks can change, even mid-year,” Norris sai d.
Ask for an Exception
However, it’s not always possible to avoid out-of-network charges. If you know you’re going to need to seek care from an out-of-network medical provider, Norris said you may be able to negotiate with your insurer to get a network exception.
One situation that may warrant a network exception is when there are no in-network providers within a reasonable distance. Another is when the out-of-network provider has a level of expertise that’s superior to the available in-network providers for a particular procedure.2
Fair Health Consumer. “When Out-of-Network Care Can Be Covered In Network.”
“These sorts of exceptions are fairly rare, because insurers are required to maintain adequate networks,” Norris said. “But it never hurts to ask.”
Negotiate With the Provider
If you know you’re going to be paying for the out-of-network care yourself, you can try to negotiate a lower price directly with the medical provider. Norris explained that they may offer you a discounted rate in exchange for paying cash or for agreeing to a short payment time frame.
Common Surprises That Complicate Insurance Billing
Even if you do your best to choose in-network hospitals and doctors, you may be met one day with a surprise out-of-network bill.
For example, if you experience a medical emergency, you could be taken to and treated at the nearest hospital regardless of whether it’s in-network. Or if you’re having surgery at an in-network hospital, the anesthesiologist or assistant surgeon could still be out-of-network. If this happens, you could be left with a bill for the difference between what the provider charges and what your insurance pays, which is known as “balance billing”
Centers for Medicare & Medicaid Services. “HHS Announces Rule To Protect Consumers From Surprise Medical Bills.”
Fortunately, the No Surprises Act will take effect in 2022, protecting people from most of these types of surprise bills. “This legislation will mean that consumers will no longer be left on the hook for out-of-network charges in emergency situations or if they receive care from an out-of-network provider while at an in-network facility,” Norris said.