Insurance Provider Networks

While shopping for health insurance it's important to know what a provider network is and how it affects the price you pay for health care. This article explains in detail the advantages of going in-network and exactly what that means.

What Is An Insurance Provider Network?

Basically a provider network is another way of classifying the wide range of doctors, specialists, hospitals, and other facilities that your insurance plan works best with. Often referred to as PPO networks, each of these providers (another name for doctors, hospitals, etc.) has agreed to a contract with your insurance company. This contract includes negotiated rates between the insurance company and provider for any given procedure or appointment, and ensures direct payment at the time of your appointment. This contacted rate includes both the insurance company’s portion of the bill and your share, which may be in the form of a co-payment, deductible or coinsurance.

Reasons To Go In-Network:

Less Hassle: Visiting a doctor that you already know accepts your plan can help you focus less on the process of seeking treatment and more on feeling better.
Less Out-Of Pocket Costs: Since the insurance company and your doctor have already agreed on a price for the services you need, your visit itself will cost less. You should also only have to pay your deductible at the time of your appointment so there are less out of pocket costs.
No Need To File A Claim: Going in-network guarantees your insurance company will be billed directly, so there’s no need to pay upfront and then file a claim for reimbursement. This being said, you may still need to complete a claim form, depending on your plan.

How To Find An In-Network Provider

Once you’ve purchased an insurance plan you will have access to a large network of providers, typically organized into an extensive online database. These tools allow you to search for specific doctors or hospitals in your area and also provide important contact details for each provider. If you are unsure how to locate this tool or you need to find a doctor quickly you can always contact your insurance company for guidance.

Tip: When setting up an appointment with a doctor, be sure to have your insurance card handy and verify they accept your insurance plan. When calling, remember that doctors won’t necessarily recognize the name of your insurance plan, but they will recognize the name of the provider networks they work with.

Out-Of-Network Care

While it is not ideal, there may be times when you need to visit a doctor outside of your network. Keep in mind that these providers have not agreed to a set any rate with your insurance company, so you may be charged more for the same services. Depending on your plan, you may also be charged higher deductibles and coinsurance, or your plan may not cover out-of-network care at all. Assuming your plan will cover these expenses, you will need to file a claim with your insurance company for reimbursement.

Tip: Generally out-of-network doctors will still accept you as a patient, but if direct billing to your insurance company cannot be arranged you will be responsible to pay the cost of treatment at the time of your visit.

Reasons To Go Out-Of-Network:

Situations that may require you to visit an out of network provider:

If you are seriously ill or injured and have no time to search for an in-network hospital.
Your primary care physician might refer you to a specialist who is not a part of your network.
If you have a serious illness many providers will be involved in your treatment. Even though your hospital is in your network some providers such as the anesthesiologists or radiologists, might not be.

Tip: You shouldn’t assume that your primary care physician knows the details of your insurance plan. If you do need a referral, remind your doctor what insurance coverage you have and request a specialist in your network.

Emergency Care

In the case of a life-threatening injury or illness insurance companies know that the closest emergency room may not be in-network. Because of this, many plans provide coverage for emergency situations, regardless of where treatment is sought. To help minimize expenses, your insurance company will typically ask you will be moved to an in-network provider for any follow-up care once your condition is stable.

Tips For Managing Your Costs

Sometimes going outside your network for care is unavoidable. However, the choice is up to you and that choice should be an informed one. You can follow these tips to help manage your costs when going out of your network:

Confirm, Confirm, Confirm — If you’re having a complex procedure like a surgery, confirm that all doctor’s involved participate in your plan.
Ask Questions — If you do choose to go out-of-network, find out how much your visit will cost beforehand. This will give you the opportunity to talk to your insurance company and find out how much of that cost your insurance plan will cover.
Carry Your ID Card — In the case of an unexpected emergency, having your insurance information on your person will allow doctors to quickly contact your insurance company.
Make A List — Create an easily accessible list of in-network hospitals, doctors and urgent care centers around your home. Having a premade list of providers will help ensure your family knows the closest and most cost-efficient places to seek treatment.

Finding a doctor that participates with your insurance plan shouldn’t be difficult, but if you do experience difficulties be sure to contact your insurance company for help. In case you have already visited an insurance provider and would like further information ont the reimbursement process, be sure to read our article The Claims Submission Process in Detail.

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